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.
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.
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?*

YesNo
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)?*

YesNo
Do you have any of the following medical conditions? (Check all that apply.)*

Chronic obstructive pulmonary disease (COPD)Congestive heart failure (CHF)Obstructive sleep apnea (OSA)Morbid obesity with a body mass index (BMI) greater than 35Recent heart attack or heart stent placement within the last one yearRecent pulmonary embolism (PE) or deep vein thrombosis (DVT) within the last six monthsStroke within the last one yearUncontrolled hypertensionNone of these apply to me
Have you previously had a colonoscopy?

YesNo
Acknowledgements

By checking the boxes below you are indicating that you understand and consent to the following insurance/billing disclaimers.
I understand I am not referred by my primary care provider under this program and this procedure will be billed as such with my insurance.
I understand that I am responsible for payment for all services rendered, whether covered or not.
Should be Empty:

Screening Colonoscopy Intake Form

Personal Information

Insurance Information

Health Information

Acknowledgements