Direct Access Colonoscopy

1
Do you currently have any of the following GI symptoms?* This field is required.(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
YESNO
2
Are you on any of the follow blood thinner medications?* This field is required.Coumadin (warfarin), Plavix (clopidogrel), Xarelto (rivaroxaban), Eliquis (apixaban), Pradaxa (dabigatran), Effient (prasugrel), or Lovenox (enoxaparin)
YESNO
3
Do you have any of the following medical conditions?* This field is required.[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
YESNO
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:

SCHEDULE AN APPOINTMENT
5
Patient's Name* This field is required.
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6
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7
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8
Patient's Cell Phone Number* This field is required.
9
Patient's Alternative Phone Number (Optional)
10
Do you wish to received reminder text and phone calls about your appointments?* This field is required.
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11
Patient's Email* This field is required.
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12
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13
Upload Photo IDPlease upload a copy of your photo ID, such as a driver's license or passport.
14
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15
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16
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17
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18
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19
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20
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21
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22
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23
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24
Primary Insurance Plan (HMO/IPA)* This field is required.Please select your IPA or medical group.
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25
Primary Insurance Member ID #* This field is required.For TRICARE patients: use the "Benefits Number" listed on the back of your ID card. For Medicare patients: use your Medicare Number.
26
Upload FRONT of Primary Insurance Card
27
Upload BACK of Primary Insurance Card
28
Do you have a secondary insurance policy?* This field is required.
YESNO
29
Secondary Insurance Type* This field is required.
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30
Secondary Insurance Plan (PPO/POS/EPO)* This field is required.Please select your primary health insurance policy's carrier.
Blue Shield of California
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31
Secondary Insurance Plan (HMO/IPA)* This field is required.Please select your IPA or medical group.
Healthcare Partners
Associated Hispanic Physicians (AHP)
Health Care LA IPA
Stewart Medical Group
Advanced Medical Doctor of CA (AMDC)
Southland San Gabriel Valley
Southland Advantage
Regal / Lakeside Medical Group
32
Secondary Insurance Member ID #* This field is required.For TRICARE patients: use the "Benefits Number" listed on the back of your ID card. For Medicare patients: you may use your Medicare # or social security number.
33
Medi-Cal Issue Date (Secondary Insurance)* This field is required.Please enter the Issue Date listed on your Medi-Cal card.
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34
Upload FRONT of Secondary Insurance Card
35
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36
Do you have a tertiary insurance policy?* This field is required.
YESNO
37
Tertiary Insurance Type* This field is required.
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38
Tertiary Insurance Plan (PPO/POS/EPO)* This field is required.Please select your primary health insurance policy's carrier.
Blue Shield of California
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Aetna
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Blue Cross/Blue Shield Federal Employee Program
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39
Tertiary Insurance Plan (HMO/IPA)* This field is required.Please select your IPA or medical group.
Healthcare Partners
Associated Hispanic Physicians (AHP)
Health Care LA IPA
Stewart Medical Group
Advanced Medical Doctor of CA (AMDC)
Southland San Gabriel Valley
Southland Advantage
Regal / Lakeside Medical Group
40
Tertiary Insurance Member ID #* This field is required.For TRICARE patients: use the "Benefits Number" listed on the back of your ID card. For Medicare patients: you may use your Medicare # or social security number.
41
Medi-Cal Issue Date (Tertiary Insurance)* This field is required.Please enter the Issue Date listed on your Medi-Cal card.
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42
Upload FRONT of Tertiary Insurance Card
43
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44
Is someone else financially responsible for your medical bills (guarantor)?* This field is required.*Required for minors less 18 years-old
YESNO
45
Guarantor's Name* This field is required.
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46
Relationship of Guarantor* This field is required.
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47
Guarantor's Date of Birth* This field is required.
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48
Guarantor's Address* This field is required.
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Denmark
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Northern Mariana
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49
Guarantor's Phone Number* This field is required.
50
Guarantor's Email* This field is required.
example@example.com
Confirm Email
51
Were you referred by another doctor or healthcare provider?* This field is required.
YESNO
52
Referring Provider's Name* This field is required.
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53
Referring Provider's Address
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Laos
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Malta
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Mayotte
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Nagorno-Karabakh
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Niue
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Northern Mariana
Norway
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Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
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Solomon Islands
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eSwatini
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Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
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Other
Country
54
Is the referring provider also your primary care provider (PCP)?* This field is required.
YESNO
55
Do you have a primary care provider (PCP)?* This field is required.
YESNO
56
PCP's Name* This field is required.
Dr.
Dr.
NP
PA
Other
Prefix
First Name
Last Name
57
PCP's Address
Street Address
Street Address Line 2
City
Please Select
Please Select
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58
Have you had a colonoscopy before?* This field is required.
YESNO
59
How recent was your last colonoscopy?* This field is required.
1 year ago or less
3 years ago
5 years ago
10 years ago
60
Name of the doctor who perform your last colonoscopy* This field is required.
Dr.
Dr.
NP
PA
Other
Prefix
First Name
Last Name
61
Result of Last Colonoscopy* This field is required.If known, please specify that type of colon polyps that were found on your previous colonoscopies.
Normal
Polyp(s)
Poor Preparation
Hemorrhoid
Diverticulosis
Don't remember
62
Do you have a history of colon polyps?* This field is required.
YESNO
63
Types of Colon Polyps* This field is required.If known, please specify that type of colon polyps that were found on your previous colonoscopies.
Hyperplastic Polyps
Adenomas
Sessile Serrated Adenomas
Inflammatory Polyps
Don't Know
64
Do you have a personal history of colon cancer?* This field is required.
YESNO
65
Do you have a family history of colon cancer?* This field is required.
YESNO
66
Family Members with Colon Cancer* This field is required.Please list any known family members with colon cancer. Click "SAVE" after each new entry.
67
Past GI Medical History - Esophagus* This field is required.Do you have any of the following GI-related medical problems of the esophagus?
None
Heartburn/GERD/Acid Reflux
Barrett's Esophagus
Reflux Esophagitis
Eosinophilic Esophagitis
Esophageal Stricture or Narrowing
Achalasia
Esophageal Spasm
Esophageal Cancer
Zenker's Diverticulum
68
Past GI Medical History - Stomach* This field is required.Do you have any of the following GI-related medical problems of the stomach?
None
Stomach Cancer
Gastric Ulcer
Gastrointestinal Bleeding
H. Pylori Infection
Gastroparesis
Gastritis
69
Past GI Medical History - Small/Large Intestine* This field is required.Do you have any of the following GI-related medical problems of the small or large intestine?
None
Crohn's Disease
Ulcerative Colitis
Irritable Bowel Syndrome (IBS)
Colon Polyps
Colon Cancer
Diverticulosis
Diverticulitis
Chronic Constipation
Chronic Diarrhea
Duodenal Ulcer
Celiac Disease
Microscopic Colitis
70
Past GI Medical History - Anorectal* This field is required.Do you have any of the following GI-related medical problems of the anus or rectum?
None
Hemorrhoid
Anal Fissure
Anal Fistula
Perianal Abscess
Anal Cancer
Anal Wart
71
Past GI Medical History - Liver* This field is required.Do you have any of the following GI-related medical problems of the liver?
None
Abnormal Liver Tests
Hepatitis B
Hepatitis C
Liver Cirrhosis
Liver Cancer
Liver Transplant
Alcoholic Liver Disease
Fatty Liver Disease/NASH
72
Past GI Medical History - Pancreas/Gallbladder* This field is required.Do you have any of the following GI-related medical problems of the pancreas or gallbladder?
None
Acute Pancreatitis
Chronic Pancreatitis
Pancreatic Cancer
Gallstones
Cholecystitis
Gallbladder Cancer
Cholangiocarcinoma
73
Other Past Medical History* This field is required.Do you have any of the following non-GI medical problems?
None
Diabetes
High Blood Pressure
High Cholesterol
Coronary Artery Disease
Heart Attack
Heart Failure
Heart Valve Problem or Murmur
Atrial Fibrillation/Atrial Flutter
Abnormal Heart Rhythm
Peripheral Vascular/Arterial Disease
Blood Clots in Vein (DVT or PE)
COPD
Sleep Apnea
Asthma
Chronic Kidney Disease
End-stage renal disease (Dialysis)
Non-GI Cancer
Anemia
Bleeding Disorder
Morbid Obesity (BMI >40)
Endometriosis
Seizure Disorder
HIV
Stroke/TIA
Thyroid Disorder
Drug/Chemical Dependent
Anxiety
Depression
Active or Latent TB
74
Past Surgical/Procedure History* This field is required.Have you have any of the following surgeries or procedures done?
None
Gastric bypass/Weight loss surgery
Colon Resection
Cholecystectomy (Gallbladder)
CABG (Coronary Artery Bypass)
Heart Valve Surgery
Coronary Stents Placement
Pacemaker/Defibrillator Placement
Peripheral Vascular Bypass
Hysterectomy
Kidney Transplant
Liver Transplant
Whipple's
Small Bowel Resection
Ileostomy or Colostomy
Hemorrhoid Surgery or Banding
Hernia Repair
75
Do you drink more than 5 drinks of alcohol per week?* This field is required.
YESNO
76
Are you currently taking any medications?* This field is required.
YESNO
77
Current MedicationsPlease list all medications you're currently taking. Note: click "SAVE" after each new entry.
78
Do you have any drug or non-drug allergies?* This field is required.
YESNO
79
Allergies* This field is required.Please list all allergies and their reactions. Click "SAVE" after each new entry.
80
Cancellation Policy* This field is required.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.
81
Notice of Privacy Policy* This field is required.Click the link below to see our Notice of Privacy Policy.
82
Patient Payment Policy & Procedure Billing Information* This field is required.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.
83
Signature* This field is required.
Clear
84
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