Follow Up Coordination

Please complete this form to allow ColonoscopyAssist to effectively co-ordinate your follow up care.
Patient Information
First Name
Last Name
Follow Up Coordination
What follow up care do you need?

Please be specific (eg. Follow up consult with colorectal surgeon). It is best if you are able to provide the CPT codes.
What city and state would you prefer to have your follow up care?
ColonoscopyAssist will do its best to negotiate a discounted cost of follow up care for you. However, please keep in mind that this is not our core competency and that ColonoscopyAssist makes no guarantee that it will be able to help. Patients should continue to make arrangements to coordinate their own follow up care incase ColonoscopyAssist is unable to help.
Patient ID
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- I have read and understand that statement above

Patient Information