Direct Access Colonoscopy Qualification Questionnaire

Bergen New Bridge Medical Center - Paramus, New Jersey 07652
Direct Access Colonoscopy Qualification Questionnaire
Our Direct Access Colonoscopy Program allows eligible patients to schedule a screening colonoscopy without a separate pre-procedure office visit. By completing this form, you may qualify for direct scheduling and avoid delays caused by extra appointments. We realize that some patients are more comfortable meeting the physician prior to the procedure. If you would prefer to schedule an in-person consultation to discuss colonoscopy for colon cancer screening, please indicate that at the end of this form or contact our GI office. Our staff is ready to answer your questions and support you through every step of the process.

Bergen New Bridge Medical Center - Paramus, New Jersey 07652
Direct Access Colonoscopy Qualification Questionnaire
Demographic Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*
If other, please specify
Phone Number*
Email Address*
example@example.com
Insurance/PCP/Pharmacy Information
Insurance Name*
Insurance Subscriber ID Number*
Insurance Group ID Number*
Primary Care Physician*
Pharmacy Name*
Pharmacy Address*
Medical History
1. Do you have any current gastrointestinal symptoms?*

NoYes
1a. If yes, please explain.
(cont.) If yes, please explain.
2. What medical conditions have you been diagnosed with (e.g., hypertension, diabetes, etc.)?*
(cont.) What medical conditions have you been diagnosed with (e.g., hypertension, diabetes, etc.)?
3. What abdominal or pelvic surgeries have you had previously (e.g., gallbladder removal, appendix removal, hernia repair, c-section, hysterectomy, etc.)?*
(cont.) What abdominal or pelvic surgeries have you had previously (e.g., gallbladder removal, appendix removal, hernia repair, c-section, hysterectomy, etc.)?
4. Do you currently smoke cigarettes or consume alcohol excessively?*

NoYes
4a. If yes, please explain.
(cont.) If yes, please explain.
5. Do you have a family history of colon cancer?*

NoYes
5a. If yes, which side of the family?
6. Please list all prescribed and over-the-counter medications you are currently taking.*
(cont.) Please list all prescribed and over-the-counter medications you are currently taking.
7. Do you have any allergies to medications?*

NoYes
7a. If yes, which medications?

Bergen New Bridge Medical Center - Paramus, New Jersey 07652
Direct Access Colonoscopy Qualification Questionnaire
Please upload a picture of the front and back of your insurance card below.
Front of Insurance Card*

Cancelof
Back of Insurance Card*

Cancelof

Bergen New Bridge Medical Center - Paramus, New Jersey 07652
Direct Access Colonoscopy Qualification Questionnaire
Benefits: Colonoscopy is a proven, life-saving procedure used to screen for and prevent colorectal cancer, the second leading cause of cancer-related death in the U.S. The procedure involves the use of a flexible camera to examine the colon and rectum. Prior to the procedure, the patient undergoes a cleansing bowel preparation to maximize the effec- tiveness of the test. Most patients experience little to no discomfort due to conscious sedation anesthesia. If polyps or abnormalities are found, they can usually be removed during the procedure, reducing cancer risk.

Risks: A colonoscopy is generally a very safe procedure that can be lifesaving; however, as with all medical procedures, there are some potential risks involved. These risks include bleeding, infection, missed abnormalities, colon perforation requiring repair, and adverse reactions to sedation. These complications are rare and are generally outweighed by the benefits of early cancer detection and prevention.

By submitting this form, I acknowledge that I have answered the questions to the best of my ability, and that I have read and understand the stated risks and benefits related to the colonoscopy procedure. I understand that the GI team will review my responses and contact me within 5–7 business days regarding next steps.
Print Name*
Patient Signature*

Clear
Date/Time
Print Physician Name
Physician Signature

Clear
Date/Time

MonthDayYear
Date
Should be Empty:

Bergen New Bridge Medical Center - Paramus, New Jersey 07652

Direct Access Colonoscopy Qualification Questionnaire

Bergen New Bridge Medical Center - Paramus, New Jersey 07652

Direct Access Colonoscopy Qualification Questionnaire

Demographic Information

Insurance/PCP/Pharmacy Information

Medical History

Bergen New Bridge Medical Center - Paramus, New Jersey 07652

Direct Access Colonoscopy Qualification Questionnaire

Questionnaire

Bergen New Bridge Medical Center - Paramus, New Jersey 07652

Direct Access Colonoscopy Qualification Questionnaire

Bergen New Bridge Medical Center - Paramus, New Jersey 07652

Direct Access Colonoscopy Qualification Questionnaire