Charlotte Gastroenterology & Hepatology | Easy Access GI Referral Form

Thank you for choosing Charlotte Gastroenterology and Hepatology as your GI referral of choice. In keeping with our commitment of excellence in customer service, we developed this “Easy Access GI” form to provide easier access to our appointment schedule. Simply complete the information below and fax this form back to the number provided. We have a fax line dedicated only to receiving these appointment referrals:

EASY ACCESS GI
FAX LINE: (704) 602-6576

You have a choice, by fax or phone, in how you receive the information regarding the appointment. We will also call the patient direct, if you so choose. If referring to a particular physician within our practice, be sure to include his/her name and location choice. Please have your Medical Records Dept. fax records as soon as possible prior to the scheduled appointment to 704-375-6970. Our appointment coordinators are available to assist you with any of your appointment needs. Again, thank you for choosing Charlotte Gastroenterology and Hepatology!

Patient Name*
First Last
Date*
Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
Insurance Carrier Name
Home Phone*
### ###-####
Mobile Phone
### ###-####
Work Phone
### ###-####
Additional Information
Call Patient to Confirm Appointment*
- Yes
- No
Appointment date by*
- Phone
- Fax
Reason for Referral*
- Routine
- Stat Request
Physician Requested
Locations Requested
Referring Physician/Practice
Referral Coordinator
Phone Number
### ###-####
Fax Number
### ###-####
Medical Offices
Charlotte Office
2015 Randolph Rd., Ste. 208
Charlotte, NC 28207
David G. Scholz, MD
Gardiner Roddey, MD
Simon S. Prendiville, MD
Sanjib P. Mohanty, MD
Jason A. Wilson, MD, AGAF, FACG
Atul Khanna, MD
Rebecca E. Rawl, MD, MPH

Matthews Office
1340 Matthews Township Pkwy.,
Ste. 301
Matthews, NC 28105
Sam R. Fulp, MD
Jeffrey S. Zaidman, MD
Srinivas Cheruvu, MD, MSPH
Viral D. Patel, MD

Ballantyne Office
Ballantyne Medical Two Building
15830 Ballantyne Medical Pl., Ste. 175
Charlotte, NC 28277
James L. Toussaint, MD
Dennis D. Kokenes, MD
Robert J. Schmitz, MD
Ashish D. Thekdi, MD

Huntersville
The Park
13808 Professional Center Drive
Huntersville, NC 28078
Steven A. Josephson, MD
Scott A. Brotze, MD
Devi Thangavelu, MD
Vinaya C. Maddukuri, MD
Nicholas R. Crews, MD

Mooresville
115 Commerce Pointe Blvd.
Mooresville, NC 28117
John H. Moore, III, MD
Steven A. Josephson, MD
Scott A. Brotze, MD
Michael W. Ryan, MD
Devi Thangavelu, MD
Vinaya C. Maddukuri, MD
Nicholas R. Crews, MD

GI Procedures

Endoscopy

Endoscopy is a safe medical procedure that uses a thin, flexible tube, equipped with a light and camera, to view the interior of the gastrointestinal system. Endoscopy can be performed in our Randolph Road, Ballantyne, Huntersville, and Mooresville offices. Learn More

Colonoscopy

Colonoscopy is an out-patient procedure used to screen for colorectal abnormalities, including cancer and precancerous conditions. A physician inserts a colonoscope, a long, flexible, tubular instrument, which transmits an image of the lining of the colon onto a screen, enabling the doctor to view any abnormalities. Learn More

Upper Endoscopy

An upper endoscopy observes the inside of the upper digestive tract — the esophagus, stomach, and first part of the small intestine. Learn More

Endoscopic Ultrasound

Endoscopic ultrasound is a minimally invasive procedure that combines endoscopy and ultrasound to produce highly detailed images of the lining and walls of the upper and lower gastrointestinal tract. These sound wave-produced images are used to determine the cause of symptoms of abdominal pain, or to diagnose or determine the spread of certain types of cancer. EUS is also a valuable tool in evaluating certain lung diseases or viewing organs such as the pancreas, gallbladder, and liver. Learn More

ERCP

An endoscopic retrograde cholangiopancreatogram is a procedure that combines the use of a flexible, lighted scope (endoscope) with X-rays to examine the ducts of the gallbladder, pancreas, and liver. Learn More

Infusion Therapy

For the convenience of our patients, we offer a four-chair infusion center at our Randolph Road office location. Learn More

Breath Testing

A breath test is a painless and non-invasive way to diagnose a number of gastrointestinal disorders. During a breath test, patients will breathe into a machine that takes samples to test for one of the four conditions below Learn More

Capsule Endoscopy

Capsule endoscopy allows physicians to examine the lining of the small intestine. This part of the GI tract cannot be reached by traditional upper endoscopy or by colonoscopy. Learn More

Radiofrequency Ablation for Barrett’s Esophagus

Radiofrequency ablation is a treatment used for Barrett’s esophagus which uses radio waves to kill precancerous and cancerous cells in the Barrett’s tissue. An electrode mounted on a balloon or an endoscope creates heat to destroy the Barrett’s tissue and precancerous and cancerous cells. Learn More

Easy Access GI Referral Form

Additional Information

Medical Offices