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 Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. What is your age? What is your height? What is your height?: Feet feet What is your height?: Inches inches What is your weight? Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Are you pregnant or possibly pregnant? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Do you have a history of severe constipation or inadequate prep for a previous colonoscopy? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Have you had difficulty with sedation or anesthesia in the past? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. 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 Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Do you have a pacemaker or a defibrillator? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Are you taking any blood thinners such as Coumadin/Warfarin, Plavix/Clopidogrel, Xarelto/Rivaroxaban, Pradaxa/ No Dabigatran, Eliquis/Apixaban? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Are you being treated for a lung condition or do you use oxygen at home? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Are you being treated for kidney failure or receiving dialysis? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Do you have advanced liver disease (cirrhosis)? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Are you a recipient of an organ transplant? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Do you have any medical problems that are currently difficult to control? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Have you been treated for acute diverticulitis in the past 2 months? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Do you have iron deficiency anemia or blood in the stool? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Do you have Ulcerative Colitis or Crohn's disease? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. Have you had a colonoscopy in the past 10 years? Yes No Please be advised that, based on your response, we encourage you to call the office and schedule a consultation with one of our experienced gastroenterologists for further evaluation. Many of these consultations are available virtually, so you may not need to visit the office in person. 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 - Alabama Alaska American Samoa Arizona Arkansas Armed Forces (Canada, Europe, Africa, or Middle East) Armed Forces Americas Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Preferred Phone Alternative Phone Were you referred by a CityMD location? Yes No What is the name of the doctor or CityMD location 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 Jersey New York NJ locations: - Select - 1 Diamond Hill Road, Berkeley Heights, NJ 630 Commons Way Bridgewater, NJ 67 Walnut Avenue, Clark, NJ 6 Brighton Road, Clifton, NJ 140 Park Avenue, Florham Park, NJ 123 Highland Avenue, Glen Ridge, NJ 85 Raritan Avenue, Highland Park, NJ 75 E. Northfield Road, Livingston, NJ 7 Centre Drive, Suite 11, Monroe Township, NJ 477 Route 10 East, Suite 204, Randolph, NJ 25 Morris Avenue, Springfield, NJ 10 Mountain Boulevard, Warren, NJ 375 Mt. Pleasant Avenue, West Orange, NJ NY locations: - Select - 50 Court Street, Suite 1102, Brooklyn, NY 11201 200 Motor Pkwy, Suite C, 14/15, Hauppauge, NY 11788 2035 Lakeville Road, New Hyde Park, NY 11040 535 5th Avenue, New York, NY 10017 3030 Westchester Avenue Purchase, NY 10577 243 Boyle Road, Selden, NY 11784 73 Market Street Yonkers, NY 10710 Who would you like to perform the procedure? Farshad Abir Adam F. Barrison? Konika P. Bose William Brown Roger S. Klein Gloria Lan 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. Book a consultation If any of the responses above advise you to call the office to schedule a consultation, we recommend that you do not submit this form and instead contact the office directly to arrange your appointment.
