Gastroenterology Specialties, P.C. & Lincoln Endoscopy Gold Change Form

Patient Name

First Last

Patient Medical Record #

Current Date

Reschedule or Cancel

Procedure

Other Procedure type

With

Other with

Original Date/Doctor/Location

Since the time we scheduled your last procedure, have you had any of the following? (mark for 'Yes')

Started or stopped any prescription Wt loss medications or Blood Thinning medications
Had any new heart problems or heart procedures
Had any other major medical issues

Explain any new conditions or meds marked above

Does patient response have a timeframe and/or location requirement?

Schedule 5-7 days out due to new medication
Facility restriction due to heart issues/procedure, oxygen use, dialysis, or stroke

Change Date

Is the procedure date within 30 days of an appt?

Was procedure ordered at the appt?*

Nurse to send prepro to*

Doctor/Location

Arrival Time

Reschedule/Cancel By

Procedure Time

Reason*

Orders Given

Order Changes

Changes

Does the patient speak English*

INTERPRETER NOTIFIED OF CANCEL/RESCHEDULE*

Scheduler Name

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