Pacific Gastroenterology Associates Referral Form Completed Form Examples and Samples

View a detailed, filled-out example of the Pacific Gastroenterology Associates Referral Form. This sample serves as a practical guide for referring physicians, demonstrating how to correctly complete the form with patient history, relevant lab results, and procedure requests.
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Completed Pacific Gastroenterology Associates Referral Form for a patient with suspected IBD.

Pacific Gastroenterology Associates Referral Form Example

How this form was filled:

This sample referral form is filled out by a General Practitioner for a patient presenting with chronic abdominal pain and weight loss, suspected to have Inflammatory Bowel Disease (IBD). The form details the patient's clinical history, relevant lab results (elevated CRP and Fecal Calprotectin), and a request for a semi-urgent colonoscopy.

Information used to fill out the document:

  • Patient Name: Jane A. Smith
  • Patient Date of Birth: 1995-07-22
  • Patient Personal Health Number (PHN): 9876 543 210
  • Patient Address: 456 Oak Avenue, Vancouver, BC, V5K 0A1
  • Patient Phone Number: (604) 555-0189
  • Referring Physician: Dr. Robert Brown, MD
  • Referring Physician Billing #: 12345
  • Referring Clinic: City Central Medical Clinic
  • Clinic Phone: (604) 555-0145
  • Clinic Fax: (604) 555-0146
  • Date of Referral: 2026-06-10
  • Urgency: Semi-Urgent (To be seen within 2-4 weeks)
  • Reason for Referral: Chronic abdominal pain, unintentional weight loss. Suspected Inflammatory Bowel Disease.
  • Procedure Requested: Colonoscopy
  • Clinical History & Symptoms: 31 y/o female with a 6-month history of cramping lower abdominal pain and intermittent non-bloody diarrhea. Unintentional 10lb weight loss. Family history of Crohn's Disease (mother).
  • Relevant Lab Results: CBC: Normal. CRP: 15 mg/L (elevated). Fecal Calprotectin: 450 ug/g (elevated).
  • Relevant Imaging: Abdominal Ultrasound (2026-05-20): Unremarkable.
  • Current Medications: None.

What this filled form sample shows:

  • Clearly documented Reason for Referral with specific symptoms and suspected diagnosis.
  • Inclusion of objective clinical data, such as elevated CRP and Fecal Calprotectin levels, to justify urgency.
  • A specified Urgency Level and a direct request for a Colonoscopy to guide the specialist's next steps.
  • Complete and accurate patient and referring physician contact information for efficient scheduling and communication.

Form specifications and details:

Use Case: Primary Care Physician referral for a patient with suspected Inflammatory Bowel Disease (IBD).
Form Name: Pacific Gastroenterology Associates Referral Form
Medical Specialty: Gastroenterology
Categories: referral forms, SOC forms
Created: February 12, 2026 07:26 PM
Completed Pacific Gastroenterology Associates Referral Form for a patient with suspected IBD.