Most applications take 2–3 minutes to complete.
Our team reviews submissions within 1–2 business days.

Pre-Qualification Application for Colonoscopy Consultation

Please complete this form to confirm eligibility and schedule your visit with Dr. Kumkum Patel.
This ensures we can provide the best care and avoid delays.

Recommended For Adults 45 yrs old • Has A Family History Of Colon Cancer • Has Colon Polyps

Important: This form is for booking a colonoscopy without a prior visit to Dr. Patel. Please only use it if you do not have symptoms like diarrhea, abdominal pain, or bleeding. If you have any symptoms, please book an appointment with Dr. Patel directly.

BASIC INFORMATION

Full Name *

Date of birth *

Phone *

Email *

City *

Postal Code *

Are you 45 years or older? *

Yes

No

Are you seeking this colonoscopy primarily for screening (not urgent symptoms)? *

Yes

No

Have you ever had a colonoscopy before? *

Yes

No

If yes, when was your last colonoscopy?

MEDICAL SAFETY

Do you have a history of any of the following?

Colon Cancer

Polyps

IBD

Major Heart Condition

Major Lung Condition

Bleeding disorder

On Blood Thinners

None of the Above

Our team will review your safety info before scheduling.

Acknowledgement

I confirm I have read and agree to the financial terms.

INTENT CONFIRMATION

I am prepared to move forward with scheduling if approved *

Yes

No

Preferred timing *

Same Week

Next Week

Flexible