Patient Referral Form


Patient: DOB:
Address:

Tel.: [Home] [Bus/Cell]
Health Card:
Indication:

>= Age 50 average risk for colon cancer
Family history of colon cancer or polyps
Positive fecal occult blood testing: _____ out of _____ sets
IRON DEFICIENCY ANEMIA (Please enclose blood test report):
        Hb __________ Ferritin __________ Saturation __________
Other: ______________________________
Referring Physician Name/Number:
Date:
Tel: Fax:


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