Referral form
Colonoscopy referral
A colonoscopy referral asks a GI service or hospital endoscopy unit to book a colonoscopy for a named indication: screening, a positive FIT, bleeding, iron deficiency, or surveillance. Provincial cancer-screening programs and hospitals each print different PDFs. It is not a generic GI consult unless that is actually what you want, and it is not a CT colonography requisition.
Name the indication
Endoscopy units protocol on indication and urgency. “Colonoscopy please” without FIT result, bleeding, or family history lands in the slowest pile — or comes back. Screening in an average-risk person is not the same booking as a positive FIT or iron-deficiency anaemia.
Use the unit’s current form. Ontario’s colorectal screening program, other provincial programs, and hospital GI each have their own boxes. If the patient is already in a screening program, do not double-book a parallel private request without saying so.
FIT-positive is not “routine screening”
A positive faecal immunochemical test is a different pathway than average-risk screening. Tick the box the form uses for FIT-positive (or write it in the indication). Do not bury the result in a paragraph about constipation.
Who completes it
The referring physician or nurse practitioner. Some programs accept a primary-care requisition directly to endoscopy; others want a GI consult first. Follow the form in front of you. Do not sign a colonoscopy request for a patient you have not assessed.
How to complete the requisition
- Indication: screening, FIT-positive (include date and kit if you have it), rectal bleeding, iron deficiency, IBD assessment, polyp surveillance with last scope date and findings.
- Anticoagulation, antiplatelets, insulin, and OSA — the unit will ask anyway.
- Prior colonoscopy date and whether the bowel prep was adequate, if known.
- Allergies, implants only if the form asks (this is not an MRI).
- Urgency that matches the indication. Melena is not a six-month screen.
- Who will manage the bowel prep questions if your office is the contact.
If you actually want a GI opinion about diarrhoea or abnormal LFTs, send a consult, not a colonoscopy form. If you want CT abdomen, send imaging. Wrong modality wastes a slot.
Worked example (fictional)
Colonoscopy — FIT-positive, family practice
Fictional 58-year-old. Do not copy into a real endoscopy form.
Indication: FIT-positive 2026-07-14 (provincial screening kit). No overt rectal bleeding. No weight loss. No first-degree CRC under 60. Meds: none that anticoagulate. Diabetes on metformin only. No prior colonoscopy. Urgency: FIT-positive pathway, not average-risk screening. I am the FP. Patient aware bowel prep will come from the unit. Not a CT colonography req.
Why units send it back
- No indication, or screening ticked on a bleeding patient.
- Missing FIT date when the story is “the kit was positive.”
- No medication list for a patient on warfarin or DOAC.
- Surveillance requested with no prior scope date.
- Wrong hospital form, so the fax dies.
Draft the colonoscopy referral from the visit
In Scribeberry, open Forms, search for colonoscopy referral or endoscopy requisition, or upload the unit’s current PDF. Generate from the encounter and your notes, then review every field before you send. Scribeberry does not pre-map this form. You still review and sign. Scribeberry does not book endoscopy.
Frequently asked questions
Do I refer to GI or straight to endoscopy?
Follow the destination’s current pathway. Some FIT-positive programs accept a direct colonoscopy requisition. Symptomatic or complex patients often need a GI consult. Use the form they sent you.
Is this the same as a diagnostic imaging requisition?
No. Colonoscopy is an endoscopic procedure. CT colonography is imaging. Complete the form that matches the test you want.
What if the patient refuses bowel prep discussion in clinic?
Still send a complete indication. The unit will counsel on prep. Do not omit anticoagulants because the visit ran long.
Does Scribeberry book the colonoscopy?
No. Scribeberry helps you complete the PDF. You send it to the service. Keep a copy in the chart.
Forms
