Screening Colonoscopy Form | Gastroenterologists, P.C. | Cedar Rapids, Iowa

Gastroenterologists, P.C.

Screening Colonoscopy Form
Please fill out the form below then click the submit button. Our nurse will then contact you about scheduling your screening colonoscopy. The more thorough you are in completing the form, the quicker we can schedule you. Remember, this is for patients who are age 50 and over and have no GI symptoms. If you have symptoms, please talk to your doctor. If you have a family history of colon cancer or polyps it could be done before age 50. This information will be kept strictly confidential. Thank You!

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*Full Name:

*Birthdate:

*Address:

*Phone (Home + Best for Contact):

*Referring Physician (Name + Phone #):

Medical Illnesses:

Surgeries:

Medication/Dosage (include over the counter meds):

Drug Allergies:

Family History of Colon Cancer or Polyps?/Who/Age:

Have you had a prior colonoscopy?/When?:

Do you have any gastrointestinal symptoms?:

Facility Preference?:

Mercy
St. Lukes
Surgery Center

Insurance Information:

Other Information:

*Form completed by:

Patient
Physician's Office

Please click on the Submit button to submit the form details.

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