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 Do you weigh over 300 lbs? Yes No 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 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 5 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. - Select -1 Diamond Hill Road, Berkeley Heights, NJ465 Union Avenue, Bridgewater, NJ6 Brighton Road, Clifton, NJ31-00 Broadway, Fair Lawn140 Park Avenue, Florham Park, NJ123 Highland Avenue, Glen Ridge, NJ75 E. Northfield Road, Livingston, NJ477 Route 10 East, Suite 204, Randolph, NJ375 Mt. Pleasant Avenue, West Orange, NJ Who would you like to perform the procedure? Farshad Abir Adam F. Barrison? Tamir Ben-Menachem? Konika P. Bose William Brown J. Scott Gillin Roger S. Klein Hazar Michael Piotr Sowa Who would you like to perform the procedure? Neal E. Luppescu Who would you like to perform the procedure? Howard B. Baum 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 Yong M. Kwon Cecilia Minano Who would you like to perform the procedure? Jason Abfier Kevin J. Holzman John J. Imbesi Raymond P. Kenny 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 You should receive a response within five to seven business days.
