Scheduling Request

Procedure Scheduling Form

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We take your privacy seriously. Information you submit through this form is handled in accordance with HIPAA guidelines.

Patient Information

This form helps us collect the details needed to book your procedure. It only takes a few minutes.

Name*

First Last

Date of birth*

MM slash DD slash YYYY

Gender*

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Patient ID

Please enter an ID if you have been provided one. If left blank, a new ID will be assigned to you.

Phone*

Email*

All important communication regarding appointments will be sent to this address. Double-check for accuracy.

Are you sure that email is correct?

Please double check the email address for accuracy. Email is our primary mode of communication for appointment updates.

Text Message Opt-In*

I agree to receive text messages for scheduling and appointment reminders. This is required to ensure timely communication regarding my appointments. No marketing text messages will be sent and you can opt-out by replying STOP.

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Record Created By

Address*

Street Address Address Line 2 City State Zipcode

Authorized Contact

Would you like to designate an authorized contact to discuss your medical information on your behalf?

Benefits Code

Were you provided a benefits code by your plan or employer?

Authorized Contact

Authorized Contact Name

Provide details for any individual authorized to discuss your medical record and appointment on your behalf.

Authorized Contact Phone

Benefits Code

if you were provided a benefits code by your plan or employer, please enter it here

Insurance Use

Do you plan to use insurance for this procedure?

(This helps us guide you appropriately.)

Yes, I plan to use insurance

No, I plan to pay out-of-pocket

We are an Self-Pay program

ColonoscopyAssist is a self-pay program. This means the cost of the procedure must be paid out of pocket, directly to us.
We’ll provide you with a detailed statement after your procedure, which you can submit to your insurance for possible reimbursement.

You may still proceed with the program — we just want you to be fully informed.

Great! You’re in the right place

ColonoscopyAssist was created specifically to support self-pay patients. Our program is designed to make high-quality care more affordable and accessible, especially for those without insurance or with high deductibles.

How Do Payments Work?
You’ll make two simple payments for your appointment.
After scheduling, a first payment of up to $250 is due within 2 business days to hold your spot.
The remaining balance is due 1 week before your procedure.

What brings you in for this procedure?

Why are you scheduling a colonoscopy?*

I don’t have symptoms — this is a routine screening for colorectal cancer

I’m having symptoms and need to find out what’s going on

We can probably skip the consult

We’ll do our best to schedule you directly for the procedure without a consult.

If the provider requires one for safety reasons, we’ll let you know — but in most cases, we’re able to move straight to scheduling your colonoscopy.

What symptoms are you experiencing?*

Abdominal Pain

Acid Reflux

Bloating

Blood in stool

Constipation

Diarrhea

Rectal Bleeding

None of the above

What is the reason for your procedure?*

Let’s Check for Any Special Medical Needs

Some health conditions may require extra monitoring during the procedure. Please let us know if any of these apply to you — it helps us schedule you safely and appropriately.

Do you have any of the following medical conditions?*

(Select all that apply)

Anemia

Asthma

Anxiety

Bleeding disorder / Excessive Bleeding

COPD

Diabetic

Emphysema

Frequent Nose or gum bleeds

High blood pressure

Heart condition

Implanted cardiac pace maker or defibrillator

Kidney failure

Latex allergy

Migraines

Sleep apnea

Ulcerative colitis

Inflammatory bowel disease

Past abdominal or pelvic surgeries

Problems with anesthesia in the past

On anti-clotting medications or blood thinners (Eg. Coumadin, Plavix, Lovenox)

Heart surgery (eg. valve replacement, angioplasty, stents, heart bypass)

Weight loss medications / GLP1

None of the above

Have you ever had a complication during a similar procedure?*

(For example: trouble waking up from sedation, breathing issues, excessive bleeding, etc.)

Yes

What happened?*

Race*

White / Caucasian

Black / African American

Hispanic / Latino

American Indian

Asian

Southeast Asian

Native Hawaiian / Pacific Islander

Other

Lets Calculate Your BMI

Height (ft)*

Feet

Height (in)*

Inches

Weight*

In Pounds (lbs)

Your BMI*

Other Medical History

Current Medications

Drug Name

Strength (if known)

Previous Surgeries / Hospitalizations

Surgery

Year (approx)

Known Allergic Reactions

Scheduling Preferences

A consult is required with this provider

This provider requires a pre-consult for all patients.
No need to worry — the cost of the consult was already included in the total price displayed in our facility locator.

Scheduling completed on the phone

Scheduling for this provider must be completed on the phone. You will receive a call from us within a few business hours.

We’re collecting your availability for a consult— Just in Case

We’re not sure yet whether the provider will require a consult before your procedure. Their office will make that decision after reviewing your medical history.
In the meantime, we’re collecting your scheduling preferences so we can move quickly if a consult is needed. If it’s not, we’ll skip straight to scheduling your procedure.

Your availability for a pre-consult

What days of the week are you available for a consult?*

Select all that apply. No weekends.

Monday

Tuesday

Wednesday

Thursday

Friday

What time of day is most convenient?*

Select all that apply. No appointments after 4pm.

Mornings (8 AM – 12 PM)

Afternoons (12 PM – 4 PM)

Any specific dates you’d prefer for an appointment?*

Please enter specific dates. If you don’t we’ll determine the best date for you.

Any dates you’d prefer to avoid?

Highly recommended to answer this. You’ll be surprised at their ability to pick the one day that doesn’t work for you.

Your availability for a procedure

Lets get your scheduling preferences for the procedure

What days of the week are you available for the procedure?*

Select all that apply. No weekends.

Monday

Tuesday

Wednesday

Thursday

Friday

What time of day is most convenient?*

Select all that apply. Procedures are only performed in the mornings.

Early Mornings (6 AM – 9 AM)

Late Mornings (9 AM – 12 PM)

Any specific dates you’d prefer for an appointment?*

Most providers schedule a few weeks out for non-urgent procedures.

Do you have any specific dates you’d prefer to avoid?

Highly recommended to answer this. You’ll be surprised at their ability to pick the one day that doesn’t work for you.
Just a reminder — for a colonoscopy, you’ll need to start prep the afternoon before your appointment.
Pro tip: Try not to schedule the day after Thanksgiving… you’ll miss the big dinner!

Other Special Request (Not common)

Other Special Requests (Not common)

I prefer not to be sedated during the procedure

I already have a prep and would prefer to use that

I prefer a low volume prep (usually more expensive than regular preps)

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Reports

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Where do you want your reports sent?

Myself

Referring Physician

If you have a referring physician or a primary care physician, please enter here.
Reports will be sent to fax number provided.

Referring Physician Search

Referring Physician Practice Name

Referring Physician Name

First Last

Referring Physician Phone

Referring Physician Fax

Pharmacy Information

If the provider needs to prescribe any medication — like prep instructions for your colonoscopy — they’ll send it to your preferred pharmacy. Please share the pharmacy you’d like us to use. If you’re not sure, just enter the one you use most often.

Pharmacy Search*

Pro tip: Enter name followed by city and state to narrow down the right pharmacy.

Pharmacy Name

Pharmacy Address

Street Address Address Line 2 City State Zip Code

Pharmacy Phone

Pharmacy Fax

Other Preventative Services (Optional)

In addition to colonoscopies, we also offer screening mammograms and annual wellness lab panels. If you’re due for either, we can help you schedule them instantly — no extra forms required.

Interested in Other Preventive Services?

(optional)

Yes, I’d like to schedule a mammogram (price based on location. Usually around $200))

Yes, I’d like to schedule an annual wellness lab panel ($69 with referral)

The lab team will be in touch

Great! We’ll let the team from our lab program, LaboratoryAssist, know. They’ll be in touch shortly.

The radiology team will be in touch

Great! We’ll let the team from our diagnostic imaging program, RadiologyAssist, know. They’ll be in touch shortly.

Terms & Conditions

Please check the box to indicate your acceptance to our agreements below*

A copy of the linked documents will be emailed to you for your records.

I agree to the Terms, Conditions and Policies

Please check the box to indicate you understand this form schedules your appointment*

I understand that submitting this form will result in a confirmed appointment being scheduled on my behalf with appointment details sent to the email and phone number provided. If I do not cancel in advance, I will be responsible for no-show charges.

Please sign below to indicate that you have read and understand the agreements in the above documents and agree to all of its terms and conditions. An electronic signature will be placed on each document.

Patient Signature*

Comments

This field is for validation purposes and should be left unchanged.

Procedure Selected

Hemorrhoid Banding $350

Total$350

Facility Selected

MidAtlantic Gastrointestinal Center

< Change selected facility

Need Assistance?
1-855-542-6566

Procedure Scheduling Form

Patient Information

Authorized Contact

Benefits Code

Insurance Use

What brings you in for this procedure?

Let’s Check for Any Special Medical Needs

Lets Calculate Your BMI

Other Medical History

Scheduling Preferences

Your availability for a pre-consult

Your availability for a procedure

Other Special Request (Not common)

Reports

Referring Physician

Pharmacy Information

Other Preventative Services (Optional)

Terms & Conditions

< Change selected facility

Nationwide scheduling hotline

Mon-Fri | 7AM - 6PM CST

About ColonoscopyAssist

ColonoscopyAssist is the organization that will be scheduling your procedure. We will be responsible for :

1) Scheduling your procedure
2) Collecting any applicable payments
3) Providing you with a statement and
a copy of your report (within 4 weeks)

Patients

Providers

Organizations

Connect with us

Patients

Providers

Organizations

Connect with us

Patients

Providers

Organizations

Lets Connect!

Important Winter Storm Update

Procedure Scheduling Form

Patient Information

Authorized Contact

Benefits Code

Insurance Use

What brings you in for this procedure?

Let’s Check for Any Special Medical Needs

Lets Calculate Your BMI

Other Medical History

Scheduling Preferences

Your availability for a pre-consult

Your availability for a procedure

Other Special Request (Not common)

Reports

Referring Physician

Pharmacy Information

Other Preventative Services (Optional)

Terms & Conditions

< Change selected facility

Nationwide scheduling hotline

Mon-Fri | 7AM - 6PM CST

About ColonoscopyAssist

ColonoscopyAssist is the organization that will be scheduling your procedure. We will be responsible for :

1) Scheduling your procedure 2) Collecting any applicable payments 3) Providing you with a statement and a copy of your report (within 4 weeks)

Patients

Providers

Organizations

Connect with us

Patients

Providers

Organizations

Connect with us

Patients

Providers

Organizations

Lets Connect!

Important Winter Storm Update

1) Scheduling your procedure
2) Collecting any applicable payments
3) Providing you with a statement and
a copy of your report (within 4 weeks)