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.
Do you have any GI symptoms such as unexplained abdominal pain, uncontrolled heartburn, unexplained nausea or vomiting, chronic diarrhea, blood in stools or unintentional weight loss?
Other than baby aspirin (less than 100 mg) are you taking any blood thinners such as Coumadin (warfarin), Plavix (clopidogrel), Xarelto (rivaroxaban), Eliquis (apixaban), Pradaxa (dabigatran), Effient (prasugrel) or Lovenox (enoxaparin)?
Do you have any of the following medical conditions? (Check all that apply.)
Have you previously had a colonoscopy?
Have you previously had colon cancer?
Have you seen your Primary Care Provider in the last 365 days?
Should be Empty:

Screening Colonoscopy Intake Form

Personal Information

Insurance Information

Health Information