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Direct Access Screening Colonoscopy Program

Colonoscopy is considered the most effective method of screening for colorectal cancer. Beginning at age 50, all men and women should be screened for colorectal cancer, even if they are experiencing no problems or symptoms, and have a full colonoscopy every ten years.

To accommodate healthy patients who need a screening colonoscopy, the Digestive Disorders Institute has established a direct access program to expedite and simplify the process of scheduling colonoscopies. The Direct Access Screening Colonoscopy Program allows select patients in stable health to arrange for a colonoscopy without first having a face-to-face consultation with a gastrointestinal specialist.

For more information about the Direct Access Screening Colonoscopy Program, click here.

To request an appointment for a screening colonoscopy, please provide the following information:

Patient First Name: *

Patient Last Name: *

Patient E-mail Address:

Patient Date of Birth: *

Daytime Phone:*
--

Best Time to Call:

Insurance
Carrier: *

Memeber ID #: *

Chief Complaint:

Present Illness (if none, indicate "none"): *

Past Medical History (check all that apply/if none, indicate "none")*
Asthma(AS)

Atrial Fibrilation (Afib)

Breast Cancer (BC)

Colon Cancer (CRC)

Congestive Heart Failure (CHF)

COPD

Coronary Artery Disease (CAD)

Diabetes Mellitus (DM)

Heart Attack (MI)

Hypertension (HTN)

Lymphoma (LYM)

Melanoma (Mel)

Obesity (Ob)

Ovarian Cancer (OC)

Prior Colon Polyps (PCP)

Seizure Disorder (SZD/O)

Sleep Apnea on CPAP (OSA)

Stroke (CVA)

Uterine Cancer (UC)

None


Other:

Previous Operations(if none, indicate "none"): *

Family History (check all that apply/if none, indicate "none")*
Celiac Disease

Colon Cancer

Crohn's Disease

GI Cancer

Prior Colon Polyps

None


Other:
Social History
Smoking:
Yes No

Recreational Drugs:
Yes No

Alcohol:
Daily Weekly Rarely Never

Medications(if none, indicate "none"): *

Allergies (include foods/medications/materials e.g., latex/if none, indicate "none"): *


Family Physician
Name:

Address:

Phone:
--





Important Note:

The Stony Brook Medicine University Physicians website is primarily an informational and educational resource. It should not be used in place of medical advice and recommendations you receive from your health care provider. If you have, or suspect that you have a medical problem or condition, please seek the advice of your health care provider.


Stony Brook Medicine University Physicians provides marketing advice and consultation to the clinical Faculty associated with the University Faculty Practice Corporations (UFPCs). It does not provide medical care directly or indirectly nor does it oversee, direct, manage or supervise the medical care provided by any of the individual Practices. The individual Practices are responsible for the medical care each Practice provides to its patients. Please note that the Practices listed below are separate University Faculty Practice Corporations (UFPCs).