OAC FORM (Step 1)

Open Access Colonoscopy Questionnaire

Gastrointestinal Associates has developed a program which allows healthy individuals to schedule screening colonoscopy without the need for an office visit before the procedure.

EVERY QUESTION MUST BE ANSWERED OR WE WILL NOT BE ABLE TO SCHEDULE AN OPEN ACCESS COLONOSCOPY. Be advised that a Nurse from our office will review, and depending upon the answers, you may need to have an Office Visit prior to the Colonoscopy. Someone from our office will contact you.

Please complete the following questionnaire and submit online.

  • Open Access Colonoscopy at our institution is approved for patients age 50 to 70 in good health.



    Those who desire colon cancer screening below age 50 or above age 70 are encouraged to schedule an office visit to determine if screening is medically appropriate.

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Gastrointestinal Associates (OAC)
1095 Rydal Road, Suite 100
Rydal, PA. 19046
Phone: 267-620-1100
Fax: 267-620-1188

Gastrointestinal Associates (OAC)
708 Shady Retreat Road, Suite 9
Doylestown, PA 18901
Phone: 267-620-1100
Fax: 215-348.3780

Patient Statement for Open Access Colonoscopy:

I have reviewed the Open Access Colonoscopy Questionnaire and have answered all questions truthfully to the best of my knowledge.

  • Open Access Colonoscopy is designed to allow healthy, age appropriate patients to have a screening colonoscopy without an office visit. The Questionnaire that I have completed will be carefully reviewed and I may be called for points of clarification. For my safety, depending on the answers provided, I understand I may be scheduled directly for a Screening Colonoscopy or if I do not meet open access criteria, an office visit will be scheduled.
  • I understand that by choosing to pursue Open Access Colonoscopy I have not, nor during this process will I have, a GI consultation. I understand that I have the choice to make an appointment for an office visit to discuss colonoscopy and the risk, benefits and alternatives and have declined to do so. I also understand that I will require a separate office visit to address any GI complaints I might have.
  • If I am scheduled directly for a Screening Colonoscopy I will be sent information by mail regarding preparation for the procedure, the procedure itself, and post-procedure concerns. I will read the information provided and make sure that I understand and will be able to comply with the instructions given.
  • I understand that, while not likely, there are risks involved with colonoscopy as with any medical procedure. These risks are outlined in the information that I have received. I have reviewed this information to my complete satisfaction and I understand the risks and the benefits of colonoscopy.
  • Should I have any changes in my health status or insurance after being scheduled, or any questions about the information I receive by mail I will call the office at 267-620-1100.
  • I understand that I must have someone drive me to the procedure and wait in the unit to drive me home. Without a driver in attendance the procedure will be cancelled.



GASTROINTESTINAL ASSOCIATES, INC.
PATIENT REGISTRATION

Welcome to our practice. Please complete all sections of this registration form. Thank you.

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