Pacific Gastroenterology Associates Referral Form Instructions

Enter any extra clinical details, special instructions, scheduling preferences, or other important information relevant to this referral (e.g., brief history, precautions, or documents to be attached).

Enter the date on which this referral was made.

Check this box if the patient's primary language or preferred language for care is English.

Check this box to indicate 'Yes' for the adjacent language/alert question (i.e., the preceding item applies).

Check this box to indicate 'No' for the adjacent language/alert question (i.e., the preceding item does not apply).

Enter the patient's other preferred language (spell out the language name) if it is not English. Fill only if 'Other Language' is 'Yes'.

Check this box if the patient speaks a language other than English and note the specific language in the adjacent space.

Check this box if the patient has a documented VRE (vancomycin‑resistant Enterococcus) positive result and should be flagged for infection‑control precautions.

Check this box when the patient should be referred to the next available specialist rather than a specific provider (1st choice of specialist not guaranteed).

Enter the preferred specialist (name or clinic/doctor identifier) the patient would like to see for the next available appointment.

Enter the patient's full legal first and last name as it should appear on the referral.

Enter the patient's complete residential address including street, city, province/state, and postal/zip code.

Enter the patient's Personal Health Number or other government-issued patient identifier exactly as it appears on their health card.

Enter the patient's date of birth.

Enter the patient's gender or gender identity as the patient identifies it.

Enter the patient's home telephone number, including area code.

Enter the patient's mobile or cell phone number, including area code.

Enter an alternate telephone number for the patient (for example work or secondary contact), including area code.

Check this box when you are attaching the patient's past medical history documentation. Fill only if 'Prior visit to a Gastroenterologist? - Yes' is 'Yes'.

Check this box when you are attaching a current medication list or medication administration record. Fill only if 'Prior visit to a Gastroenterologist? - Yes' is 'Yes'.

Check this box when you are attaching any procedure reports and pathology results relevant to the referral. Fill only if 'Prior visit to a Gastroenterologist? - Yes' is 'Yes'.

Check this box when you are attaching bloodwork or microbiology results, diagnostic imaging, and/or consultant letters. Fill only if 'Prior visit to a Gastroenterologist? - Yes' is 'Yes'.

Check this box if the patient HAS previously seen a gastroenterologist for the condition being referred (attach reports if available).

Check this box if the patient has NOT previously seen a gastroenterologist for the condition being referred.

Check this box when imaging or a physical exam suggests a high likelihood of cancer and the patient needs urgent gastroenterology evaluation.

Check this box when the patient has a new diagnosis of IBD or is experiencing an active flare-up requiring specialist assessment or management.

Check this box when the patient has worsening difficulty swallowing (progressive dysphagia) or painful swallowing (odynophagia) that requires evaluation.

Check this box when the patient presents with jaundice (yellowing of skin or eyes) that requires gastroenterology/hepatology investigation.

Check this box when the patient is being referred for evaluation of rectal bleeding.

Check this box when the referral is for investigation or management of iron deficiency anemia.

Check this box when the patient is being referred for assessment or management of celiac disease.

Check this box when the referral is due to a positive fecal immunochemical test (FIT).

Check this box when the referral is for ongoing (stable) difficulty swallowing (dysphagia).

Check this box when the referral is for severe gastroesophageal reflux disease or severe dyspepsia symptoms.

Check this box when the patient is being referred for evaluation of severe abdominal pain.

Check this box when the referral is for a new change in bowel habits (frequency, consistency, or pattern).

Check this box when the referral is for assessment or management of viral hepatitis.

Check this box when the patient has stable IBD (not an active flare) and is being referred for routine management or follow-up.

Check this box when the referral is for evaluation or management of suspected or known IBS.

Check this box when the referral is for chronic gastroesophageal reflux disease or chronic dyspepsia symptoms.

Check this box when the patient has chronic constipation or chronic diarrhea and is being referred for assessment or management.

Check this box when chronic abdominal pain is the primary reason for the referral.

Check this box when the referral is for evaluation or management of pancreatitis.

Check this box when the referral is for surveillance colonoscopy or follow-up after prior adenomas or colon cancer.

Check this box when the referral is for cancer screening (for example colorectal cancer screening).

Check this box when the patient is being referred specifically for screening for Barrett's esophagus.

Check this box when abnormal liver function tests or known cirrhosis are the reason for referral.

Check this box when the referral is for a liver condition not specified elsewhere (other liver disease).

Enter the specific 'Other' reason for referral under Category C that is not listed among the checkboxes. Fill only if 'Category C - Other' is 'Yes'.

Check this box when the reason for referral fits none of the listed Category C options and provide the specific reason in the accompanying notes.

Enter the referring provider's full name (first and last).

Enter the referring provider's MSP or provider registration number.

Enter the name of the referring provider's clinic or practice.

Enter the clinic's full mailing address including street, city and postal code.

Enter the clinic's main phone number for contact or appointments.

Enter the clinic's fax number (if available).

Enter the phone number for the clinic's referral or scheduling desk.

Enter the patient's general practitioner or family physician's name if different from the referring provider.