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Questionnaire Before Your Test
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Patient Referral Form
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For Patient's Use
Questionnaire Before
Your Test
For Doctors' Use
Patient Referral Form
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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