Gastroenterology Specialties, P.C. & Lincoln Endoscopy Referring Office

For Referring Offices Only.

Please fill out the Referral Form below.

Referring office*
Referring Provider*
Referring office phone number*
Referral Reason*
- Office consultation
- Screening Colonoscopy (No symptoms/no history of polyps)
- Diagnostic Colonoscopy (patient with symptoms)
- EGD (patient with symptoms)
- Specialty Endoscopy (EUS or ERCP)
Symptoms for Consultation*
Symptoms for Diagnostic Colonoscopy*
Symptoms for EGD*
Indications for EUS or ERCP*
Please call Susan S or Rosie at 402-465-4545 for urgent cases
Patient Name*
First Last
Patient Date of Birth*
Date Format: MM slash DD slash YYYY
Patient Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Patient Cell Phone
Other Phone
Insurance Carrier
Plan ID #
Group Name
Group #
Optional records upload
Accepted file types: pdf.
You may also fax records to 402-465-9011
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Comments
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Referring Office