Direct Access Colonoscopy Questionnaire

Almost finished! Give us just a few more details.

Tell us about yourself.

First Name*

Last Name*

Birthday*

Age*

Address*

ZIP Code

Phone*

Email*

Primary Care Physician Information

First Name

Last Name

Phone

Do you have a preferred physician, or would you like the first available appointment?

Preferred Practice

Preferred Provider

BMI Calculation

Enter your height

Feet*

Please enter a number less than or equal to 8.

Inches*

Please enter a number less than or equal to 12.

Enter your weight (pounds)*

Please enter a number less than or equal to 1500.

Your BMI*

Status

This field is hidden when viewing the form

Eligible

This field is hidden when viewing the form

Ineligible

Questionnaire Consent

The answers provided will be used to determine your plan of care and will become part of your permanent medical record. If you are completing the questionnaire on behalf of the patient, verify the accuracy of each answer before submitting.

Depending on the results of your questionnaire, you may be eligible to schedule your colonoscopy and bypass the pre-procedure visit. However, we realize some patients are more comfortable meeting the physician prior to the procedure.

Please select one of the options below:

If eligible, I would like to proceed with scheduling the colonoscopy directly.

Regardless of my eligibility, I would like to schedule an office visit with my physician to discuss the procedure before the colonoscopy.

Congratulations! Based on the responses you submitted in our Direct Access Colonoscopy medical questionnaire, you are eligible for our Direct Access Program. In the coming days, a team member will contact you to discuss your questionnaire, answer remaining questions, and schedule your procedure.

We are committed to providing high-quality care and appreciate the significance of your treatment decision.

The United Digestive Team

Thank you for completing our online Direct Access Colonoscopy medical questionnaire. Unfortunately, your responses indicate that you do not currently meet the criteria for the Direct Access Program and will require an office visit. A dedicated team member will contact you within 2 business days to discuss your situation, answer questions, and get you scheduled with one of our providers. If you would like to contact us directly, please call 404-888-7590.

We appreciate your understanding and look forward to assisting you further.