Open Access Colonoscopy Questionnaire

Open Access Colonoscopy Screening
SCOD has developed a program which allows healthy individuals to schedule a screening colonscopy without the need for an office visit before the procedure. If you are NOT SYMPTOMATIC and your physician has suggested you have a colonoscopy (or you are between the ages of 45-75 and never had a colonoscopy), you may qualify for this program. If you are having GI symptoms/problems, your insurance will not classify this as a screening and you will need to be seen in a GI doctor's office prior to a colonoscopy. Of course, not all patients will be able to SAFELY undergo a colonoscopy without a more detailed evaluation of their health history and their risks for the procedure. If that is the case for you, we will help point you in the right direction to be assessed and determine how to best meet your health needs.
Patient Information
Name:*

First, Middle initial Last
Gender:*

MaleFemale
Phone Number:*

Area Code Phone Number
Birthdate:*
XX/XX/XXXX
Age:*
Primary Care Physician:*
Preferred Pharmacy/Location:*
Please be specific
SSN:
XXX-XX-XXXX
Address*

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email:*
example@example.com

INSURANCE INFORMATION
Policy Holder Name:*
Address (if different from patient):
SSN:
XXX-XX-XXXX
Birthdate:*
Guarantor's Employer:
Occupation:
Primary Insurance Company:
Type?
ID# or Policy#?
Group #?
Insurance Address
Insurance Phone
Secondary Insurance Company:
ID# or Policy#?
Group #?
Please Upload a Photo of the FRONT OF YOUR INSURANCE CARD:

Browse Files

Cancelof
Please Upload a Photo of the BACK OF YOUR INSURANCE CARD:

Browse Files

Cancelof
Please Upload a Copy of the FRONT OF YOUR DRIVERS LICENSE OR PHOTO ID:

Browse Files

Cancelof
Please Upload a Copy of the BACK OF YOUR DRIVERS LICENSE OR PHOTO ID:

Browse Files

Cancelof
Should be Empty:

	No	Yes	If yes, explain condition
Hospitalization in the last 3 months
Coronary Artery Bypass or Stent Placement
Congestive Heart Failure
Defibrillator
Pacemaker
Heart Valve Replacements
COPD/Emphysema
Uncontrolled Asthma
Uncontrolled Diabetes
Kidney Failure or Dialysis
Organ Transplant
Ulcerative Colitis/Crohn's Disease
Home Oxygen
Sleep Apnea

Open Access Colonoscopy Screening