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Saturday Screening Colonoscopy

Please take a moment to fill out this medical history form, which will then be reviewed by our medical staff. If approved, you will be directly scheduled for a screening colonoscopy, without a prior doctor’s office visit. All of your information will be sent securely, and your information will remain safe and confidential. 


* = required field

Personal Information:

Insurance Provider Information:

Allergies:

Tobacco Use:

Alcohol Use:

Street/Illicit Drug Use:

Medical History:

Medications

Do you take any of the following blood thinners? (provide dose/frequency)

Do you take any of the following arthritis medications? (provide dose/frequency)

Other medications you are taking (Include over the counter medications, vitamins, and doses)

Family History:

Additional Comments/Information

Digestive Health


Looking for a gastroenterologist?

Free Physician Referral Service:

1.800.321.6244