DAC colonoscopy form

Patient name*

First NameLast Name

:What is your middle initial?

Date of birth*

Date

What is your home phone number?*

Please enter a valid phone number.

Cell Phone*

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

What is your email address?*

example@example.com

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Social Security Number

Gender*

MaleFemale

Marital Status:

SingleMarriedWidowed

Race

Are you Hispanic or Latino

YesNo

Language

Referring Doctor (if any)?

Do you have an advanced directive?

I don't have an advanced directive (or I don't know what this is)Living WillDo Not Resuscitate (DNR)Do Not Intubate

Do you want access to our online portal?

YesNo

Primary Care Doctor?

Preferred pharmacy?

Location of preferred pharmacy?

Emergency contact:

Phone Number:

Please enter a valid phone number.

Relationship:

How did you hear about us?

OnlineFriendProviderOther

Who referred you?

What is your name?

First NameLast Name

Are you the parent/guardian?

YesNoN/A- I'm an adult and can make my own decisions.

Person responsible for Bill:*

Address if Different from Above?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Insurance:

Group Number:

ID Number:

Subscriber Name:

First NameLast Name

Subscriber date of birth:

Date

Secondary Insurance (if you have it):

Group Number:

ID Number:

Subscriber Name:

First NameLast Name

Subscriber date of birth:

Which bowel prep would you prefer?*

GolytelySuprepSutab

Have you had recent bleeding in your bowel movements?*

YesNo

Have you had recent abnormal bowel movements, and if so, how?*

Do you take any blood thinners (Eliquis, Warfarin/Coumadin, Predaxa, etc)?*

YesNo

Why are you on blood thinners?

Do you have a pacemaker or defibrillator*

PacemakerDefibrillatorNo

What is your cardiologist's name?

Do you have problems with anesthesia?*

YesNo

What kind of problems do you have with anesthesia?

Have you ever had an incomplete colonoscopy?*

YesNo

Why did you have an incomplete colonoscopy?

When was your last colonoscopy (or write n/a if none)?*

Do you use any recreational drugs?*

YesNo

Are you diabetic?*

YesNo

Are you allergic to latex?*

YesNo

Do you have anxiety?*

YesNo

Have you had diverticulitis in the last 6 weeks?*

YesNo

Please enter your weight and height.*

Do you take any of these medications: Phentermine, Ozempic, Wegovy, or Rybelsus*

YesNo

I acknowledge that this information provided to Kitsap General Surgery is accurate and current.*

I authorize release of any information acquired in the course of treatment necessary to complete and file medical claims to my insurance company or Medicare on my behalf. I herby acknowledge financial responsibility for cost of services rendered for me or for the person whose account I am acting as guarantor. I authorize (assign) any insurance or Medicare benefits to be paid directly to Kitsap General Surgery, PLLC or its assignees. I am responsible for any non-covered services, supplies, co-payments or deductibles. I am responsible for knowing how my plan works when I request medical services at this office. This acceptance and assignment will be in force all future services by practitioners from this office.

Signature of patient or patient's guardian/representative?*

Name of person who signed above.*

First NameLast Name

Date

I understand that as part of my health care, Kitsap General Surgery originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment,

A means of communication among the many health professionals who contribute to my care,

A source of information for applying my diagnosis and surgical information to my bill,

A means by which a third-party payer can verify that services billed were actually provided, and

A tool for routine healthcare operations such as assessing quality.

Kitsap General Surgery has a responsibility to protect the privacy of your health care information and to provide a Notice of Privacy Practices that describes how your health care information may be used and disclosed, how you can access your health information, and whom to contact if you have any questions, concerns, or complaints. We may change the Notice of Privacy Practices at any time. You may obtain a current copy of the Notice of Privacy Practices or ask questions at anytime.

I have had an opportunity to receive and review the Notice of Privacy Practices of Kitsap General Surgery.

Signature of patient or patient's guardian/representative?*

Name of person who signed above.

First NameLast Name

Date

Name of Individual

First NameLast Name

Relation

Phone Number

Please enter a valid phone number.

Name of Other Individual

First NameLast Name

Relation

Phone Number

Please enter a valid phone number.

Colonoscopy/EGD Questionnaire

There are three types of bowel preps that you can take.

Golytely is a gallon of prep that has a salty type of taste. It is usually covered by insurance. Most pharmacies have it on hand.

Suprep are two bottles (16 ozs each) that taste very syrupy. Not all pharmacies have it and not all insurances cover it. In general, it costs around $100 if your insurance doesn't cover it.

Sutab are tablets that are taken with plenty of liquid. It usually costs less than $60.

Please answer the following questions

Financial Policy, Assignment Information, and Release of Information

Acknowledgement of Notice of Privacy Practices

Release of Medical Information