Telehealth New Patient Visit Forms
- Welcome Letter- Telehealth
- Advance Directives Information
- Authorization to Release Healthcare Information
- Financial Responsibility
- Medicare Secondary Payor form
- Notice of Privacy Practices
- Notice of Privacy Practices Acknowledgement
- Patient Demographic Form
- Patient Information Form (PIF) - Clinic
Telehealth Visit Instructions
Capsule Endoscopy
Colonoscopy Coverage
Driver/Escort Resources
Financial Policy and Assistance
IBD and COVID-19 - ACG Information
New Patient Forms – Procedure
General Procedure Information:
- Advance Directives Information
- Driver-Escort Resources
- Driver-Escort Responsibilities
- Notice of Privacy Practices
- Notice of Privacy Practices Acknowledgement
- Patient Demographic Form
- Patient Information Form (PIF)
- Patient Rights and Responsibilities
- Welcome Letter – Procedures
Colonoscopy:
- Colonoscopy Coverage – What You Need To Know
- Colonoscopy Informed Consent
- Informed Consent Disclosure for Colonoscopy
EGD:
New Patient Forms – Office Visit
- Advance Directives Information
- Authorization to Release Healthcare Information
- Medical Records Release
- Notice of Privacy Practices
- Notice of Privacy Practices Acknowledgement
- Patient Demographic Form
- Patient Information Form (PIF)
- Welcome Letter – Office
Procedure Preparation Instructions
These procedure preparation instructions are for the sole use of GA patients, as directed by a GA provider. Do not take a procedure preparation other than that which is prescribed by a GA provider specifically for you. Colonoscopy preparation can very rarely cause a potentially life-threatening sodium or magnesium imbalance and due to this our preps should not be undertaken except under the advisement of a GA provider.
Colonoscopy Preparations:
- Colon Prep Split Dose Miralax + Gatorade
- Colon Prep Split Dose Miralax + Gatorade - Spanish
- Colon Prep Split Dose Miralax + Gatorade - Vietnamese
- Colon Prep Split Dose Miralax + Low Calorie Gatorade
- Colon Prep Split Dose Colyte (3L)
- Colon Prep Split Dose Colyte (3L) - Spanish
- Colon Prep Split Dose Colyte (3L) - Vietnamese
- Colon Prep Split Dose Colyte (4L)
- Colon Prep Non-Split Colyte (4L)
- Colon Prep 2-Day Split Dose Colyte (5L)
- Colon Prep 2-Day Split Dose Miralax + Gatorade
- Colon Prep Split Dose SUPREP + Bisacodyl
EGD (Gastroscopy) Preparation:
ERCP Preparation:
Flexible Sigmoidoscopy Preparations:
- Flex-Sig, FS-EGD, FS-EUS Non-Split Miralax
- Flex-Sig, FS-EGD, FS-EUS, Non-Split (2L) Colyte
- Flex-Sig, FS-EGD, FS-EUS Tap Water Enema
Hemorrhoid Banding Preparation:
Pre-Procedure Diabetes: