Gold Change Form Gastroenterology Specialties Gold Procedure Form Patient Name First Last Patient Medical Record # Current Date MM slash DD slash YYYY Reschedule or CancelRSCXProcedureColonoscopy - 45378Colon & EGD - 45378/43235EGD - 43235EGD for Capsule placement - 91110EGD/Flex Sig - 43235/45330EGD w/EUS - 43235/43259EGD/Pouchoscopy - 43235/44385Endoscopic Ultrasound - 43259EUS/ERCP - 43259/43260EUS/colon - 43259/45378ERCP - 43260ERCP w/poss Stent/Sphinc - 43262/43274ERCP w/ stent removal - 43275Flexible Sigmoidoscopy - 45330Hemorrhoid Banding - 46221Liver Biopsy - 76942Anorectal Motility - 91122PEG Placement - 43246Pouchoscopy - 44385Rectal Ultrasound - 45391Other Procedure type Withw/ Dilationw/Botox Injw/Halow/Bravow/Spyglassw/Fwd/Sidewiew scopew/Poss ERBEw/MACw/Bandingw/GENw/Flouroscopyw/stent removalOtherOther with Original Date/Doctor/Location Change Date MM slash DD slash YYYY Is the procedure date within 30 days of an appt? YES NO Nurse to send prepro to* Doctor/Location Arrival Time Reschedule/Cancel ByPatientGESProcedure Time Reason*FinancialChanged MindPersonal ConflictSicknessWorkTransportationFeeling BetterOffice RescheduleWeatherDeathUnable to contact for H&PMoved up per Wait ListOrders GivenMailPhoneMedchatNo New orders givenOrder ChangesYESNOChanges Does the patient speak English* Yes No INTERPRETER NOTIFIED OF CANCEL/RESCHEDULE* NOTIFICATION ACKNOWLEDGEMENT Scheduler Name