Campbell River Direct to Endoscopy Program
(CRDTE) FAX Number 250-286-7115
Clinic to acknowledge receipt of referral by faxing ☐Acceptance letter or ☐Incomplete/returned letter
Campbell River Direct to Endoscopy Program (CRDTE)
Island Healthy March 2020
MSP# ☐ This is the Primary Care provider
Street Address STAMP HERE
Family Physician (if different from referring physician)
Date of birth Day Month Year
Translator required ☐Yes ☐No I
f yes, patients first language
C. Procedure(s) Requested (indicate All that apply)
☐ Gastroscopy ☐ Colonoscopy ☐ Flexible sigmoidoscopy +/- Banding
Requested Endoscopist: ☐ Next Available ☐ Specified_________________________________________________________
E. Reason For Referral (required results listed in bold)
☐Iron deficiency anemia(CBC, Ferritin, anti-tTG, IgA)
☐Radiologic suspicion of CA (radiology report)
☐Barrett’s (include most recent gastroscopy/pathology)
☐Blood mixed WITHIN stool
☐Chronic GERD (>5y, no prior gastroscopy)
☐Prior colon CA (include pathology and colonoscopy note)
) not meeting CSP criteria
☐Celiac confirmation (anti-tTG and IgA)
☐Prior polyps not meeting CSP criteria (include pathology and colonoscopy note
☐Diarrhea >6 weeks (anti-tTg, GPMP)
☐+Fit not meeting CSP criteria (FIT results)
☐outlet bleeding (blood on tissue or in toilet)
Inflammatory Bowel Disease
☐Inflammatory bowel disease requiring surveillance (include GI report if available
☐ Yes ☐ No If yes, was previous endoscopy done in VIHA ☐ Yes ☐ No
CRDTE is a centralized referral program that streamlines requests for GI ENDOSCOPY at Campbell River General (CRG).
Referred patients must meet the following criteria.
1. Referrals must only be for non-emergent (> 3 weeks) GI endoscopy. Requests for emergent procedures (within 3 weeks) must be
arranged with on-call surgeon (e.g. high likelihood CA, severe dysphagia, active IBD, obstructive jaundice, severe Dysphagia).
• By calling the CRG switchboard at 250-286-7100
2. Candidates for colonoscopy with BC Colon Screening Program (CSP) will be RETURNED to the referring Physician.
• http: / / www.bccancer.bc.ca / screening / health-professionals / colon / eligibility
3. Referrals for office assessment / consultation alone should be directed to individual specialist’s offices.
4. NOT Eligible for CRDTE referral: Patients who are on dual antiplatelet medications, cardiac stents < 6 months, stroke/MI < 3 months,
need for bridging heparin.