By submitting this form, I confirm that the information I have provided is accurate and complete to the best of my knowledge. I understand that submitting this form does not guarantee that I qualify for an Open Access Colonoscopy and does not establish or confirm an appointment.
I understand that my information will be reviewed by the medical team to determine whether Open Access Colonoscopy is appropriate for me and that this form may not be secure. Any health information I choose to share on this form is at my own risk. Based on my medical history, medications, symptoms, or other risk factors, I may be asked to schedule a consultation with a gastroenterology provider before a procedure can be scheduled.
I understand that this form is not intended for urgent or emergency medical concerns. If I am experiencing a medical emergency, I should call 911 or seek immediate medical care.
