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Patient Name:

Date of Birth:

Primary Insurance:

Insurance ID Number (please include prefix):

Secondary Insurance:

Insurance ID Number (please include prefix):

Previous colonoscopy?

Yes No

Doctor

Date

Facility

History of/currently experiencing symptoms: Check all that apply.

Rectal Bleeding

Change in Bowel Habits

Mucus in Stool

Diarrhea

Abdominal Pain

Blood Thinning Medications

(including aspirin)

Anorectal Issues

(hemorrhoids, fissures, fistulas)

Cardiac Issues

Anemia

Diabetes

Latex Allergy

Family History of Colon/Rectal Cancer

Family History of Colon Polyps

Colon Polyps

Complications with Anesthesia

None of the above

Please explain any yes answers:

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Date

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Alaska Colorectal Surgery

June George MD, Daniel Rossi DO; Kerrie Bossard MD, Rebecca Rowen MD

Phone:(907) 222-1401, Fax: (907) 222-1402

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