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7 Day Scope Referral

Please complete and submit the form below

"*" indicates required fields

Referral Type*

Red Flag

Routine

Urgent

Procedure Funding Method*

Self-funding

Insurance funded

Name*

First Last

Date of Birth

DD slash MM slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Contact Number

NHS H&C Number

Gender at Birth

Male

Female

Referral Details

Referring Clinician

Date of Referral

MM slash DD slash YYYY

Endoscopy procedure required

Clinical indication for procedure

Clinical history*

Current Medications*

Is patient on blood thinners?*

Yes

No

Which blood thinner and dose?

Is the patient diabetic?*

Yes

No

Allergies

Last eGFR (ml/min) for Colonoscopy only.

Must be within the last 3 months

Date eGFR taken

MM slash DD slash YYYY

Kingsbridge Private Hospital

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*Credit acceptance is subject to status. Terms and conditions apply. Kingsbridge Private Hospital trading as Kingsbridge Private Hospital Group is an Appointed Representative of Chrysalis Finance Limited, which is authorised and regulated by the Financial Conduct Authority to carry out the regulated activity of credit broking.

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