Patient's Details

*Surnames *DOB
*First Names NHI
*Address Tel (home)
Tel (work)
Insurer Tel (mobile)


Colonoscopy   Consultation
  Gastroscopy   Bowel cancer screening

*Clinical Details

  Comorbid conditions


Cardiac Warfarin/Clopidogrel
Respiratory Aspirin/NSAIDS
Diabetes mellitus Allergies or anaesthetic problems
Other Other

Referring Doctor

Preferred report type
*Name Telephone  
Medical Centre Fax
*Postal Address Email
EDI Report to:

*Validation Code

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