Patient Type
New
Returning Patient
First Name
Last Name
Date of birth
-- month --
1
2
3
4
5
6
7
8
9
10
11
12
-- day --
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-- year --
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Gender
Male
Female
Address
City
State
Zip
Phone Number
Phone Number Confirmation
Email
Preferred Location
-- please select --
Main Office – Homewood
Alabaster
Cullman
Gardendale
Pell City
Pell City Internal & Family Medicine
Simon-Williamson Clinic
St. Vincent’s One Nineteen
Sylacauga
Trussville
Southview Medical Group
St. Vincent’s Chilton
Alabama Digestive Health and Endoscopy Center (ADHEC)
Birmingham Surgery Center
Brookwood Baptist Medical Center
Coosa Valley Medical Center
Grandview Endoscopy Center
Grandview Medical Center
Shelby ASC
Physician Endoscopy Center at 119
St. Vincent’s St. Clair
Surgery Center of Cullman
St. Vincent’s Chilton
How did you hear about us?
-- please select --
Google, Bing, Etc.
Facebook, Instagram, TikTok
Referral from Doctor
Recommended by a Friend
Event
Other
Returning Patients Only:
Has your insurance changed?
Yes
No
Not Insured?
Yes
No
How did you hear about us (other):
Insurance Carrier
Insurance ID #
Do you have secondary insurance
Yes
No
Secondary Insurance Carrier Name
Secondary Insurance Carrier ID #
Primary Care Doctor
What would you like to schedule:
Office Visit:
Screening Colonoscopy, Age 45+
Please select Preferred Time of Day if
Screening Colonoscopy, Age 45+
is selected:
First Available
Morning
Lunch
Late Afternoon
Have you had a colonoscopy before?
Yes
No
If yes, was a polyp found?
Yes
No
If yes, when was your last colonoscopy?
If yes, who was your doctor?
Please select your reason for an office visit:
GERD/Acid Reflux/Heart Burn
Abdominal Pain
Constipation
Diarrhea
Irritable Bowel Syndrome (IBS)
Hemorrhoids
Other
Do you have any gastrointestinal symptoms such as abdominal pain, bleeding, weight loss, diarrhea, constipation, or anemia? If so, please explain symptoms and symptom onset date:
none
Height
Weight
Do you have any of the following apply to you?
Diabetic
High Blood Pressure
Pacemaker, Defibrillator, or Stents
Requires Oxygen
Receiving Dialysis
Kidney Disease
Seeing cardiologist for cardiac issues
Taking weight loss management drugs such as Ozempic (Semaglutide) or Mounjaro (Tirzepatide)
Taking blood thinners such as Plavix, Xarelto, Coumadin, or others?
Name and Address of Preferred Pharmacy