Procedure Intake Form
Name
First Name
Last Name
DOB
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Pharmacy
Insurance Provider Name
Policy Number
Group Number
Insurance Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Next
List approximate date of last colonoscopy:
Do you have a family history of colon cancer?
Please Select
Yes
No
Unsure
Do you have a family history of colon polyps?
Please Select
Yes
No
Unsure
Are you diabetic?
*
Please Select
Yes, I take insulin
Yes, I take oral medication
Yes, I take insulin & oral medication
No
Yes, only diet controlled
Have you been diagnosed with any liver disease or cirrhosis?
*
Please Select
Yes
No
Unsure
Do you have a pacemaker, defibrillator or AICD? If yes, please list manufacturer and model.
*
Please Select
Yes - pacemaker only
Yes - defibrillator
Yes - pacemaker/defibrillator combo
Yes - AICD
No
Unsure
Please list manufacturer and model of pacemaker/defibrillator/AICD if applicable.
Are you taking any prescription blood thinners (i.e., Plavix, Warfarin, Xarelto, Eliquis)? If yes, please list along with prescribing provider.
*
Have you had any hospitalizations or surgeries within the past 6 months? If yes, please list.
*
Are you taking any weight loss medications-over the counter or prescription? If yes, please list name of medication.
*
Do you have any of the following medical conditions:
*
Stroke or heart attack within the past 6 months
Unstable angina (chest pain)
Worsening heart failure
Severe cardiac valvular disease
Congenital heart defects
Newly diagnosed arrhythmias
Cardiac ejection fraction <30%
Lung disease/conditions that requires >3 liters of oxygen
Chronic kidney disease
Severe anaphylactic allergies including alpha gal
Impacted airways/difficult intubation
Currently pregnant
None
Height
*
Weight
*
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Any provider preference:
List any preference for day/time:
Submit
Should be Empty: