Fast Track Colonoscopy Form

Kirkland, WA

Thank you for enrolling in Gastro Health's Fast Track Screening Colonoscopy Program! Please complete all fields to the best of your ability. In order for your Fast Track Colonoscopy to be performed as safely as possible, the physicians require completing this form in its entirety. Omitting medical information could cause potential risks, including last minute cancellation of your procedure. All of your answers are secured and encrypted.


* Indicates required fields

Patient Demographics

Phone
Have you ever been a patient of our practice?*
Your Preferred Care Center Location*
Race*
Ethnicity*
Select or enter value
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Referring Doctor Information

Phone

INSURANCE INFORMATION

Do you have an insurance policy?*

Who is the policy holder for the primary insurance policy?

Select or enter value
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Do you have a secondary insurance policy?*
Select or enter value
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Patient Interview Form

Example: 5

Example: 6

Please denote in pounds. For example: 187

Pharmacy Information

Phone
I consent to obtaining a history of my medications purchased at pharmacies*

Clinical Questionnaire

Have you previously had a colonoscopy?*
Did you have any issues with the bowel preparation for your previous colonoscopy?
Do you have a family history of colon cancer?*
Have you had an asthma attack, pneumonia, or serious lung infection within the past 3 months requiring medical intervention?*
Have you been diagnosed with obstructive sleep apnea?*
Do you use a CPAP or BIPAP machine?*
Do you use oxygen at home?*
Any stroke, TIA, or new neurologic symptoms in the last 3 months?*
Have you been diagnosed with any blood clotting disorders?*
Do you have any implantable devices or heart stents?*
Have you been hospitalized in the past 6 months?*
Have you had any surgeries in the past 6 months?*

(Please type 'N/A' if no relevant surgical history)

Do you require any special accommodations?*
I am aware that sedation will be administered and I will have a responsible adult escorted ride home.*

Agreement:

Are you currently taking any GLP-1 medications for diabetes or weight loss?*
Do you use alcohol?*
Do you use marijuana or other recreational drugs?*
Tobacco or Nicotine Use*
Have you had any problems with anesthesia in the past?*
Do you get shortness of breath with regular activity?*

(for example, walking up 2 flights of stairs)

INSURANCE CARD IMAGES:

Please attach copies of the following:

  1. Front of Primary Insurance Card
  2. Back of Primary Insurance Card
  3. Front of Secondary Insurance Card (if applicable)
  4. Back of Secondary Insurance Card (if applicable)
Drag and drop files here or

If your insurance card is not provided, scheduling will be delayed.


If you cannot upload above, you can send images of the front and back of your insurance card(s) to WA001KLFastTrack@GastroHealth.com

In order for your Fast Track Colonoscopy to be performed as safely as possible, the physicians require completing this form in its entirety. Omitting medical information could cause potential risks, including last minute cancellation of your procedure.

TERMS OF ACCEPTANCE and SIGNATURE:

I, the [applicant, requestor, guardian, etc.] for this form, warrant the truthfulness of the information provided in this application:

Please type your First and Last Name

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

Please be sure to click SUBMIT below before exiting this form

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