DAC FORM

DIRECT ACCESS COLONOSCOPY
Gastrointestinal Associates has developed a program which allows healthy individuals to schedule a screening colonoscopy without the need for an office visit before the procedure.

Be advised that our office will review your submission and depending upon the answers, you may need to have an office visit prior to the colonoscopy. Someone from our office will contact you.

*A response to all questions is required in order to move forward with the submission*
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
DOB*

MonthDayYear
Date
Today Date*

MonthDayYear
Date
1. DIRECT ACCESS COLONOSCOPY AT OUR INSTITUTION IS APPROVED FOR PATIENTS AGE 45 TO 75 IN GOOD HEALTH.
Your Current Age is*
Those who desire colon cancer screening below age 45 or above age 75 are encouraged to schedule an office visit to determine if screening is medically appropriate.
2. What is your height in inches?*
What is your weight?*
BMI*
3. DO YOU HAVE ANY GASTROINTESTINAL SYMPTOMS SUCH AS:
Abdominal pain*
Bleeding*
Weight loss*
Difficulty swallowing*
Frequent diarrhea*
Personal history of colon cancer*
4. DO YOU CURRENTLY HAVE OR HAVE YOU EVER BEEN TREATED FOR ANY OF FOLLOWING:
Ulcerative colitis or Crohn’s disease*
Heart attack, irregular heartbeat, coronary artery bypass or stent placement, congestive heart failure*
Valvular heart disease*
In the last 3 months, have you been on any type of cancer therapy*
Stroke, seizure,or fainting spells*
Renal failure or dialysis*
Sleep apnea or respiratory problems (COPD, emphysema, home oxygen or active asthma)*
Defibrillator, pacemaker, or artificial heart valve*
Organ transplant other than cornea*
Diabetes*
Bleeding disorders*
5. Do you experience chest pain or shortness of breath?*
6. Do you take any blood thinners other than aspirin?*

DIRECT ACCESS (STEP 3)
PATIENT STATEMENT FOR DIRECT ACCESS COLONOSCOPY
I have reviewed the direct access colonoscopy questionnaire and have answered all questions truthfully to the best of my knowledge.
- Direct access colonoscopy is designed to allow healthy, age appropriate patients to have a screening colonoscopy without an office visit. The questionnaire that I have completed will be carefully reviewed and I may be called for points of clarification. For my safety, depending on the answers provided, I understand I may be scheduled directly for a screening colonoscopy or if I do not meet direct access criteria, an office visit will be scheduled.
- I certify that I have answered all questions correctly and completely. I understand that answering any questions incorrectly may impact my health.
- I understand that by choosing to pursue direct access colonoscopy I have not, nor during this process will I have, a GI consultation. I understand that I have the choice to make an appointment for an office visit to discuss colonoscopies and the risks, benefits and alternatives and have declined to do so. I also understand that I will require a separate office visit to address any GI complaints I might have.
- If I am scheduled directly for a screening colonoscopy I will be sent information by mail regarding preparation for the procedure, the procedure itself, and post-procedure concerns. I will read the information provided and make sure that I understand and will be able to comply with the instructions given.
- I understand that, while not likely, there are risks involved with colonoscopy as with any medical procedure. These risks are outlined in the information that I have received. I have reviewed this information to my complete satisfaction and I understand the risks and the benefits of colonoscopy.
- Should I have any changes in my health status or insurance after being scheduled, or any questions about the information I receive by mail I will call the office at 267-620-1100.
Name*
Date*

MonthDayYear
Date
Patient Signature*

Clear

DIRECT ACCESS (STEP 4)
INSURANCE COVERAGE
Please provide the details of the insurance you anticipate that you will use for this procedure. Please include all information, including plan name, that is noted on your card.
Primary Insurance Co.*
ID*
Group Number*
Secondary Insurance Co.
ID
Group Number
Please note: If your insurance information changes after you are scheduled but before the procedure, it is imperative that you call our office to alert us to avoid potential charges
Would you like a copy of your submission for your records?
If yes, please provide an email address*
example@example.com

DIRECT ACCESS COLONOSCOPY
Thank you for completing the direct access colonoscopy questionnaire.

Please click submit to determine eligibility for the program.
Thank you for completing the direct access colonoscopy questionnaire.

Please click submit to file your questionnaire.
Should be Empty:

DIRECT ACCESS COLONOSCOPY

DIRECT ACCESS (STEP 2)

DIRECT ACCESS (STEP 3)

DIRECT ACCESS (STEP 4)

DIRECT ACCESS COLONOSCOPY