DIRECT ACCESS ENDOSCOPY AND FORMS

We realize our patients have busy schedules and limited time to devote to their routine health care needs. In an effort to provide screening colonoscopy examinations in a more convenient and efficient manner.

A patient may schedule his/her colon cancer screening colonoscopy without an office visit, provided certain criteria are met, In some cases an office visit with the physician prior to any procedure is a must.

All required forms can be completed online and printed for mailing to our office. All data entered on these forms will be deleted once the web page is closed.

Forms

 

 

Instructions for Colonoscopy

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Steps to proceed with Direct Access Endoscopy:

Step 1

It is a prerequisite that all patients be informed of the risks, benefits, and alternatives to having colonoscopy. Although colonoscopy gives a highly accurate evaluation of your colon, be aware that small polyps or growths can be missed in a minority of patients.

Step 2

Please complete and sign the following forms. For your convenience, you may fill in your information online, print, sign, and mail the forms to our office.

To ensure the privacy of our patients, your data will not be saved upon exiting the web page. If you prefer, you may print the forms first and complete by hand. It is imperative that each form (4 total) is signed in the appropriate areas.

• Patient Registration Form (2 signatures)
  
• Screening Criteria Check List (1 signature)
  
• Advance Beneficiary Notice (ABN) (1 signature)
  
• Informed Consent (2 signatures)

Step 3

Our patient satisfaction and confidence in our services is our sole priority. We urge you to complete our DAE Satisfaction Survey. This survey, along with a postage paid return envelope, will be provided to you at the time of your procedure. HGA welcomes your feedback. Please help us meet our goal of providing the best medical care for our patients. See why we are one of the leading Gastroenterologists of Houston.