Paperwork to bring
Prior to your first visit to our clinic, we will mail you a personal history form to complete and bring with you to your appointment, or you may download the forms here.
We also ask that you bring, or have your referring physician send, any medical records or test results related to your condition. In addition, we will need the names and dosages of all medications you are currently taking.
General Paperwork
Please print, fill out, and bring the following 5 forms with you to your first office appointment:
Patient Registration Forms -- Patient Demographic and Insurance Information
Medical Records Release Form -- This form allows us to request medical records from your other physicians. Please sign and date this form only. If you place a doctor's name in the top portion, you will need to fill out a new form for each different physician we request records from.
Patient Interview Form -- Patient Medical History and Current Complaint information
HIPPA -- HIPPA/Information Release form
Privacy Policy -- A copy of Gastro One's Privacy Policy (read only)
Medication Reconciliation Form -- Please list all of your medications on this form, including over the counter, prescription, and herbal medications.
Procedure Paperwork
If you have an appointment for a procedure, please see the paperwork below:
Patient Instructions -- Please read the Patient Instruction booklet very carefully.
Medication Reconciliation Form -- Please list all of your medications on this form, including over the counter, prescription, and herbal medications.
Colonoscopy Diet Instructions:
Diet Instructions -- You cannot have solid food prior to your colonoscopy, so please follow these instruction carefully.
Low Fiber Diet Instructions
Bowel Prep Instructions:
Miralax Prep Instructions -- Please use these instructions if prescribed the Miralax prep by your physician.
Moviprep Instructions -- Please use these instructions is prescribed Moviprep by your physician.
Osmoprep -- Please use these instructions if prescribed Osmoprep by your physician.
Colonoscopy Tip Sheet
-- Tips for a successful colonoscopy preparation.
Upper Endoscopy Diet Instructions:
Diet Instructions-- Please follow these instructions to prepare for your Upper Endoscopy.
Open Access or Direct Access Program Paperwork
If you are taking advantage of our Open Access or Direct Access programs, please print the following information packet and follow the instructions.
Open Access Colonoscopy Patient Instructions