Gastroenterology Referral: How to Make a Referral

For Referring Physicians

All appointments and procedures for GI and endoscopy services require a referral. You can refer a patient online or by fax for:

A clinic appointment
A direct, open-access procedure

You can only directly refer a patient for a procedure without a clinic visit if the patient:

Is a Virginia resident
Doesn't have significant comorbidities
Will not need more in-depth, ongoing care

Patients should not be referred for procedures and clinic appointments at the same time. All second-opinion referrals need to come directly from the patient’s current gastroenterologist.

Make a GI Clinic Referral

Follow these steps to fax or make an online gastroenterology referral.

Referrals with Epic

If you have access, you can make an "Ambulatory GI Referral."

Want to sign up for online access to patient records and more? Learn how to get connected through EpicCare.

Fax Referrals

Fax the GI clinic referral form (PDF) to 434.244.9445.

Questions? Call 434.243.3090

Make an Endoscopy Referral

Fax the Endoscopic Procedure Order Form (PDF) to 434.924.8144.

Questions? Call: 434.924.9999

Colonoscopy Prep

Alternative Bowel Prep Guidelines

There is a national shortage of bowel preparation GoLYTELY and its alternatives (Colyte, NuLYTELY, GaviLYTE, and Trilyte). The shortage should end in Spring 2021.

We have worked with UVA Pharmacy to create a decision algorithm and protocol to standardize the ordering of alternative bowel preparations.

By doing this, we hope to reserve the limited preparations for patients who can't use alternatives.

Bowel Preparation Comparison Table

Drug Brand Name	Volume	Patient Clinical Criteria	Estimated Out-of-Pocket Cost to Patient
Miralax + Gatorade (not red or purple) + bisacodyl 10mg (5mg x 2 tabs)	238g mixed with 64 oz Gatorade	First line, unless patient meets criteria for GoLYTELY listed below	~$15
Suprep	2.8L	Second line to Miralax prep due to cost and some evidence of less efficacy	$75-$110
-GoLYTELY, GaviLyte-G (236g) -Colyte, GaviLyte-C (240g) -NuLYTELY, GaviLyte-N, Trilyte (420g)	4L	RESERVE prep for patients with the following considerations: Age ≥ 70 yo Baseline electrolyte abnormalities Severe heart failure (NYHA Class III-IV) Severe renal failure (Scr > 1.6 mg/dL or GFR < 30 ml/min) Severe cirrhosis (Childs Pugh Class B-C) History of constipation Previous inadequate bowel preparation Previous intestinal tract surgery History of spinal cord injury Pregnancy or breastfeeding	$15-$20
MoviPrep	2L	Second line to GoLYTELY and equivalents, except in patients with a history of: Known G6PD deficiency History of constipation Previous inadequate bowel preparation Previous intestinal tract surgery History of spinal cord injury	$65 (generic) $135 (brand)
Clenpiq	320 mL + at least 72oz of additional clear liquid throughout prep	If patient unable to obtain Miralax or Suprep Not part of UVA Endoscopy protocol order	$160
Plenvu	~ 2L	If patient unable to obtain Miralax or Suprep Not part of UVA Endoscopy protocol order Avoid in patients with known G6PD deficiency or phenylketonuria	$125

Gastroenterology Referrals