Screening Colonoscopy Intake Form
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State
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
*
-
Month
-
Day
Year
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
City
State
Zip Code
Please attach a photo of the front of your insurance card.
*
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of
Please attach a photo of the back of your insurance card.
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Health Information
Name of Primary Care Provider:
*
If you do not have a primary care provider enter NA
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?
*
Yes
No
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)?
*
Yes
No
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 35
Recent heart attack or heart stent placement within the last one year
Recent pulmonary embolism (PE) or deep vein thrombosis (DVT) within the last six months
Stroke within the last one year
Uncontrolled hypertension
None of these apply to me
Have you previously had a colonoscopy?
Yes
No
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.
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