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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 may schedule a colonoscopy directly with us without having to come in for an office visit.
72Questions
Direct Access Colonoscopy Registration
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  • 1
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  • 2
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  • 3
    1) Unexplained abdominal pain 2) Uncontrolled heartburn 3) Rectal bleeding or blood in your stool 4) Unexplained nausea/vomiting 5) Chronic unexplained diarrhea 6) Unintentional weight loss 7) Difficulty swallowing
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  • 4
    1) Coumadin (warfarin) 2) Plavix (clopidogrel) 3) Xarelto (rivaroxaban) 4) Eliquis (apixaban) 5) Pradaxa (dabigatran) 6) Effient (prasugrel) 7) Lovenox (enoxaparin)
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  • 5
    1) Chronic obstructive pulmonary disease (COPD) 2) Congestive heart failure (CHF) 3) Morbid obesity with a body mass index (BMI) ≥ 45 4) Heart attack or heart stent placed within the last 1 year 5) Pulmonary embolism (PE) or deep vein thrombosis (DVT) within the last 6 months 6) Unexplained anemia
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  • 6

    Unfortunate, you're not qualified!

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

    SCHEDULE AN APPOINTMENT

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    If you're not sure, select YES to enter your current contact information.
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    Please upload a copy of your photo ID, such as a driver's license or passport.
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  • 25
    If you're not sure, select YES to enter your current insurance information.
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  • 26
    ***NOTE: The only HMO we accept for direct access colonoscopy is Optum/Healthcare Partners. If you have another HMO/IPA or if your insurance is not listed, please call our office first.***
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  • 27
    Please select your primary health insurance policy's carrier.
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    Please select your primary health insurance policy's carrier.
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  • 34
    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.
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    *Required for minors less 18 years-old
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    • Cocos (Keeling) Islands
    • Colombia
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    • Maldives
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    • Marshall Islands
    • Martinique
    • Mauritania
    • Mauritius
    • Mayotte
    • Mexico
    • Micronesia
    • Moldova
    • Monaco
    • Mongolia
    • Montenegro
    • Montserrat
    • Morocco
    • Mozambique
    • Myanmar
    • Nagorno-Karabakh
    • Namibia
    • Nauru
    • Nepal
    • Netherlands
    • Netherlands Antilles
    • New Caledonia
    • New Zealand
    • Nicaragua
    • Niger
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    • Niue
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    • Northern Mariana
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    • Poland
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    • Puerto Rico
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    • 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
    • Serbia
    • Seychelles
    • Sierra Leone
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    • Thailand
    • Timor-Leste
    • Togo
    • Tokelau
    • Tonga
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