Fast Track Colonoscopy Form
Washington

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

First Name

Last Name

Middle Name or Initial

Email Address

Date of Birth

mm/dd/yyyy

Street Address

Street Address Line 2

City

State

Zip

Phone Number

Phone

Have you ever been a patient of our practice?

Yes

Your Preferred Care Center Location

Edmonds (21600 Highway 99)

Kennewick (7114 W Hood Pl.)

Kirkland (11800 NE 128 St.)

Is English your primary language

How did you hear about Gastro Health?

Referring Doctor Information

Referring Physician Name

Referring Physician Address

Referring Physician Phone Number

Phone

INSURANCE INFORMATION

Do you have an insurance policy?

Yes, I have an insurance policy

No insurance

Patient Interview Form

Height Feet

Example: 5

Height Inches

Example: 6

Weight

Please denote in pounds. For example: 187

Pharmacy Information

Pharmacy Name

Pharmacy Address

Pharmacy Phone Number

Phone

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

Yes

Clinical Questionnaire

Have you previously had a colonoscopy?

Yes

Do you have a family history of colon cancer?

Yes

Have you had an asthma attack, pneumonia, or serious lung infection within the past 3 months requiring medical intervention?

Yes

Have you been diagnosed with obstructive sleep apnea?

Yes

Do you use oxygen at home?

Yes

Any stroke, TIA, or new neurologic symptoms in the last 3 months?

Yes

Have you been diagnosed with any blood clotting disorders?

Yes

Do you have any implantable devices or heart stents?

Yes

Have you been hospitalized in the past 6 months?

Yes

Have you had any surgeries in the past 6 months?

Yes

Any other relevant surgical history?

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

Do you require any special accommodations?

Yes

I am aware that sedation will be administered and I will have a responsible adult escorted ride home.

Agreement:

Yes

Are you currently taking any GLP-1 medications for diabetes or weight loss?

Yes

Have you had any problems with anesthesia in the past?

Yes

List current or past heart or lung conditions

Do you get shortness of breath with regular activity?

(for example, walking up 2 flights of stairs)

Yes

How many times do you move your bowels per day?

Please list your current medications. Include over-the-counter medications, naturopathic remedies, herbs, and supplements.

Please list all drug allergies

INSURANCE CARD IMAGES:

File Upload

Please attach copies of the following:

Front of Primary Insurance Card
Back of Primary Insurance Card
Front of Secondary Insurance Card (if applicable)
Back of Secondary Insurance Card (if applicable)

Drop your files here

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:

ELECTRONIC SIGNATURE

Please type your First and Last Name

Acknowledgement of Signature:

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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Fast Track Colonoscopy FormWashington

Patient Demographics

Referring Doctor Information

INSURANCE INFORMATION

Patient Interview Form

Pharmacy Information

Clinical Questionnaire

INSURANCE CARD IMAGES:

TERMS OF ACCEPTANCE and SIGNATURE:

Please be sure to click SUBMIT below before exiting this form

Fast Track Colonoscopy Form
Washington