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Direct Access Colonoscopy Registration
Direct Access Colonoscopy Registration
Please fill out the following form to register for our Direct Access Colonoscopy program. If qualified, you can schedule a colonoscopy directly with us without having to come in for an office visit.
80Questions
Direct Access Colonoscopy Registration
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  • 1
    (1) unexplained abdominal pain (2) uncontrolled heartburn (3) rectal bleeding or blood in your stool (4) persistent nausea/vomiting (5) diarrhea (6) unintentional weight loss
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  • 2
    Coumadin (warfarin), Plavix (clopidogrel), Xarelto (rivaroxaban), Eliquis (apixaban), Pradaxa (dabigatran), Effient (prasugrel), or Lovenox (enoxaparin)
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  • 3
    [1] chronic obstructive pulmonary disease (COPD) [2] congestive heart failure (CHF) [3] obstructive sleep apnea (OSA) [4] morbid obesity with a body mass index (BMI) ≥ 35 [5] heart attack or heart stent placed within the last 1 year or [6] pulmonary embolism (PE) or deep vein thrombosis (DVT) within the last 6 months
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  • 4

    Thank You!

    Based on your symptoms or a medical condition that you have, it is recommended that you schedule an office consultation with one of doctors first before schedule your colonoscopy. Use the link below to schedule an appointment online:

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    If known, please specify that type of colon polyps that were found on your previous colonoscopies.
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    If known, please specify that type of colon polyps that were found on your previous colonoscopies.
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    Please list any known family members with colon cancer. Click "SAVE" after each new entry.
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    Do you have any of the following GI-related medical problems of the esophagus?
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    Do you have any of the following GI-related medical problems of the stomach?
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    Do you have any of the following GI-related medical problems of the small or large intestine?
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    Do you have any of the following GI-related medical problems of the anus or rectum?
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    Do you have any of the following GI-related medical problems of the liver?
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    Do you have any of the following GI-related medical problems of the pancreas or gallbladder?
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    Do you have any of the following non-GI medical problems?
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    Have you have any of the following surgeries or procedures done?
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    Please list all medications you're currently taking. Note: click "SAVE" after each new entry.
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    Please list all allergies and their reactions. Click "SAVE" after each new entry.
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    If you need to cancel or reschedule your procedure, please do so at least 3 business days in advance. Otherwise, you may be charged a $300 cancellation if you cancel/reschedule late or do not show up for your procedure.  Please click the link below to see our Cancellation Policy.
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    Click the link below to see our Notice of Privacy Policy.
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    When undergoing a procedure you may receive 4 separate bills: (1) from our doctors perform the procedure, (2) from the facility (surgery center or hospital) where your procedure is done, (3) from the anesthesiologist or nurse anesthetist if your procedure is done with anesthesia, and (4) from the pathology lab if you have any biopsy taken. Click the link below to see our Patient Payment Policy & Procedure Billing Information.
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