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Health Information (All Required)

Please fill out the form below to provide us with information to book your screening colonoscopy.  A pre-procedure visit may not be required. 

If you would prefer to schedule an in-person or virtual consultation to discuss colon cancer screening/colonoscopy, please click here to return to the appointment booking screen and select General Office Visit or Consult from the dropdown menu.

Did your doctor want you to have a colonoscopy because of gastrointestinal symptoms or abnormal test results?
Are you 75 years of age or older?
Do you weigh over 300 lbs?
Are you pregnant or possibly pregnant?
Do you have a history of severe constipation or inadequate prep for a previous colonoscopy?
Have you had difficulty with sedation or anesthesia in the past?
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?
Do you have a pacemaker or a defibrillator?
Are you taking any blood thinners such as Coumadin/Warfarin, Plavix/Clopidogrel, Xarelto/Rivaroxaban, Pradaxa/ No Dabigatran, Eliquis/Apixaban?
Are you being treated for a lung condition or do you use oxygen at home?
Do you have sleep apnea?
Are you being treated for kidney failure or receiving dialysis?
Do you have advanced liver disease (cirrhosis)?
Are you a recipient of an organ transplant?
Do you have any medical problems that are currently difficult to control?
Have you been treated for acute diverticulitis in the past 2 months?
Do you have iron deficiency anemia or blood in the stool?
Do you have Ulcerative Colitis or Crohn's disease?
Have you had a colonoscopy in the past 5 years?

Personal Information

Name
Are you a current patient of Summit Health?
Address
Who would you like to perform the procedure?
Who would you like to perform the procedure?
Who would you like to perform the procedure?
Who would you like to perform the procedure?
Who would you like to perform the procedure?
Who would you like to perform the procedure?
Who would you like to perform the procedure?
Who would you like to perform the procedure?
Who would you like to perform the procedure?
You should receive a response within five to seven business days.