Screening Colonoscopy Intake Form

Screening Colonoscopy Intake Form
Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Insurance Information
Policy Holder Name (if different from applicant)
Date of Birth*

MonthDayYear
Date
Insurance Plan (Entire Name)
ID #
Group #
Provider/Customer Service Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Medical Claims Address

Street Address

Street Address Line 2

CityState

Zip Code
Please attach a photo of the front of your insurance card.*

Cancelof
Please attach a photo of the back of your insurance card.*

Cancelof
Health Information
Name of Primary Care Provider:*
If you do not have a primary care provider enter NA
If you answer "YES" to any of the questions below, you are not eligible for our Direct Access program. Please contact the GVH Specialty Clinic at 970-641-3927 to schedule a consultation or, contact your primary care provider for a referral to our clinic.
YesNo
YesNo
Chronic obstructive pulmonary disease (COPD)Congestive heart failure (CHF)Morbid obesity with a body mass index (BMI) greater than 45Recent heart attack or heart stent placement within the last one yearRecent pulmonary embolism (PE) or deep vein thrombosis (DVT) within the last six monthsUnexplained anemiaPrevious history of colon cancerNone of these apply to me
YesNo
YesNo
YesNo
Should be Empty:

Personal Information