Breadcrumb Home Colonoscopy Form 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? Yes No Are you 75 years of age or older? Yes No What is your height? What is your height?: Feet feet What is your height?: Inches inches What is your weight? BMI for Adults Please upgrade to web browser that supports iframes to see this CDC widget. Please record your BMI score here 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 taking any of the following medications: Ozempic, Wegovy, Saxenda, Victoiza, Trylicity, Mounjaro? Yes No Are you being treated for a lung condition or do you use oxygen at home? Yes No Do you have sleep apnea? 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 YorkNew Jersey NJ locations: - None -1 Diamond Hill Road, Berkeley Heights, NJ704 Route 202 South, Suite 1, Bridgewater, NJ 08807465 Union Avenue, Bridgewater, NJ67 Walnut Avenue, Clark, NJ 070666 Brighton Road, Clifton, NJ31-00 Broadway, Fair Lawn140 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, NJ 0708110 Mountain Boulevard, Warren, NJ 07059375 Mt. Pleasant Avenue, West Orange, NJ NY locations: - None -50 Court Street, Suite 1102, Brooklyn, NY 11201123 William Street, 15th Floor, Suite 1503, New York, NY 10038535 5th Avenue, New York, NY 100172035 Lakeville Road, New Hyde Park, NY 11040200 Motor Pkwy, Suite C, 14/15, Hauppauge, NY 11788 Who would you like to perform the procedure? Farshad Abir Adam F. Barrison? Konika P. Bose William Brown Michael Fuhrman Brian Katz Michael Kerner Roger S. Klein Gloria Lan Marvin Lipsky Hazar Michael Piotr Sowa Who would you like to perform the procedure? Brian Katz Neal E. Luppescu 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 Raymond P. Kenny Andrew Joelson Yong M. Kwon Cecilia Minano Who would you like to perform the procedure? Jason Abfier Kevin J. Holzman John J. Imbesi Raymond P. Kenny 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? Jeffrey Danzig 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? Brian Katz Who would you like to perform the procedure? Michael Fuhrman Michael Kerner Marvin Lipsky Who would you like to perform the procedure? Michael Fuhrman Who would you like to perform the procedure? Marvin Lipsky 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? Deborah Chua Leslie Park Martin Wolff Matthew McNeill Neal Joseph Peter Kim Valerie Antoine Gustave Ugonna Iroku Who would you like to perform the procedure? Anthony Borcich Julie Foont Kati Glockenberg Martin Wolff Peter Kim Ugonna Iroku Deborah Chua Michael Glick Neal Joseph Valerie Antoine Gustave Veronika Dubrovskaya Who would you like to perform the procedure? Frederick Rutkovsky Who would you like to perform the procedure? Stanley Fox You should receive a response within five to seven business days.
