Gastroenterology/Hepatology Service

Request for Procedure

DO NOT COMPLETE IF YOU ARE: 75 years or older, if you use insulin or take a blood thinner (except for Aspirin), you will need a clinic appointment. If you are experiencing GI symptoms: blood in stool; abdominal pain; constipation; diarrhea; GERD/Heartburn; difficulty swallowing; unexplained weight loss, you will need a clinic appointment.
You are not eligible for the self-refer Open Access Program. Please contact your Primary Care Provider for a referral to be placed for a GI Clinic appointment. Please contact Referral Management to schedule that clinic appointment.
Thank you for taking time out of your busy schedule to fill out this Patient Assessment. We anticipate that having you complete this at home will enable you to complete it more thoroughly and accurately. Please don't hesitate to call the Endoscopy Unit at 301-295-4600 if you have any questions or concerns. Please allow approximately 2 weeks for our Providers to review and for you to be contacted to schedule either a clinic appointment or procedure based on your medical history. This data is protected and encrypted through SSL. Our partnership in your care will help ensure the highest quality medical care for you.

Procedure requested:*




Procedure Location. Please indicate the location you prefer to have your procedure.
You will be scheduled based on the facilities ability to provide care. Preference is not guaranteed.
Select choice #1:*





Procedure Location. Select choice #2:*





Are you an Active Duty Service Member?*

First Name:*  
Last Name:*  
Sponsor last four:*  
DOB
Month:* Day:* Year:*

Can we correspond via email?*   
If yes, Email: 
Daytime Telephone: (xxx-xxx-xxxx):*  
Evening Telephone (xxx-xxx-xxxx):  
Aspirin Use:*   
NSAID Use (Advil, Aleve, etc):*   
GERD/Heartburn:*   
PRE-SCREEN: PLEASE CHECK ALL THAT APPLY:*











GI SYMPTOMS: PLEASE CHECK ALL THAT APPLY:*