Breadcrumb Home Colonoscopy Form Health Information (All Required)Fill out the form below to provide us with information to book your screening colonoscopy. Please note: Our team will review your submission. If you are eligible, your colonoscopy will be scheduled without the need for an in-office consultation. However, some responses may require an in-office visit prior to scheduling the procedure. Did your doctor want you to have a colonoscopy because of gastrointestinal symptoms or abnormal test results? Yes No What is your age? What is your height? What is your height?: Feet feet What is your height?: Inches inches What is your weight? Are you pregnant or possibly pregnant? Yes No Do you have a history of severe constipation or inadequate prep for a previous colonoscopy? Yes No Have you had difficulty with sedation or anesthesia in the past? Yes No Are you being treated for a heart condition such as: heart attack in the past year; heart failure; heart valve problem; heart stent; abnormal heart rhythm or atrial fibrillation, or other heart conditions? Yes No Do you have a pacemaker or a defibrillator? Yes No Are you taking any blood thinners such as Coumadin/Warfarin, Plavix/Clopidogrel, Xarelto/Rivaroxaban, Pradaxa/ No Dabigatran, Eliquis/Apixaban? Yes No Are you being treated for a lung condition or do you use oxygen at home? Yes No Are you being treated for kidney failure or receiving dialysis? Yes No Do you have advanced liver disease (cirrhosis)? Yes No Are you a recipient of an organ transplant? Yes No Do you have any medical problems that are currently difficult to control? Yes No Have you been treated for acute diverticulitis in the past 2 months? Yes No Do you have iron deficiency anemia or blood in the stool? Yes No Do you have Ulcerative Colitis or Crohn's disease? Yes No Have you had a colonoscopy in the past 10 years? Yes No Personal Information Name First Last Date of Birth Are you a current patient of Summit Health? Yes No If yes, please select your primary doctor Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Preferred Phone Alternative Phone What is the name of the doctor who referred you? (if applicable) After your procedure, you may need to schedule an office visit for followup. Please select a location from the NJ / NY dropdowns. Select a Location - Select -New JerseyNew York NJ locations: - Select -1 Diamond Hill Road, Berkeley Heights, NJ630 Commons Way Bridgewater, NJ67 Walnut Avenue, Clark, NJ6 Brighton Road, Clifton, NJ140 Park Avenue, Florham Park, NJ123 Highland Avenue, Glen Ridge, NJ85 Raritan Avenue, Highland Park, NJ75 E. Northfield Road, Livingston, NJ7 Centre Drive, Suite 11, Monroe Township, NJ 477 Route 10 East, Suite 204, Randolph, NJ25 Morris Avenue, Springfield, NJ10 Mountain Boulevard, Warren, NJ375 Mt. Pleasant Avenue, West Orange, NJ NY locations: - Select -50 Court Street, Suite 1102, Brooklyn, NY 11201200 Motor Pkwy, Suite C, 14/15, Hauppauge, NY 117882035 Lakeville Road, New Hyde Park, NY 11040535 5th Avenue, New York, NY 100173030 Westchester Avenue Purchase, NY 10577243 Boyle Road, Selden, NY 1178473 Market Street Yonkers, NY 10710 Who would you like to perform the procedure? Farshad Abir Adam F. Barrison? Konika P. Bose William Brown Michael Fuhrman Brian Katz Roger S. Klein Gloria Lan Marvin Lipsky Hazar Michael Piotr Sowa Who would you like to perform the procedure? Brian Katz Who would you like to perform the procedure? Howard B. Baum Fiore De Vito Jeffrey Mark Okun Boris Reydel Who would you like to perform the procedure? Darren R. Blumberg John M. Dalena Isaac Galandauer Scott Gelman Dennis Han Kelly A. Krueger Who would you like to perform the procedure? Jason Abfier John J. Imbesi Andrew Joelson Yong M. Kwon Cecilia Minano Who would you like to perform the procedure? Jason Abfier Kevin J. Holzman John J. Imbesi Andrew Joelson Yong M. Kwon Frederick K. Shieh Who would you like to perform the procedure? Scott Gelman Who would you like to perform the procedure? Cecilia Minano Who would you like to perform the procedure? Brian Katz Who would you like to perform the procedure? Brian Katz Who would you like to perform the procedure? Michael Fuhrman Marvin Lipsky Who would you like to perform the procedure? Michael Fuhrman Who would you like to perform the procedure? Marvin Lipsky, MD, FACG Who would you like to perform the procedure? James Kim Jessica Kimmel Leslie Park Matthew McNeill Max Pitman Who would you like to perform the procedure? Valerie Antoine-Gustave Anthony Borcich Deborah Chua Veronika Dubrovskaya Julie Foont Michael Glick Ugonna Iroku Neal Joseph Peter S. Kim Martin Wolff Who would you like to perform the procedure? Peter S. Kim Who would you like to perform the procedure? Frederick Rutkovsky Who would you like to perform the procedure? Dr. Richard Fazio Dr. Andrew Francella Dr. Hashem J. Hashem Dr. Jared Macklin Dr. Alissa Mark Who would you like to perform the procedure? Peter S. Kim Who would you like to perform the procedure? Dr. David Dicaprio Dr. Jonathan Finegold Dr. Charles Koczka Dr. Mitchell Auerbach You should receive a response within five to seven business days.
