GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
M YR ON S H OH AM, M .D .
L EON A R D S F I SC HER , M .D .
R . A L L EN BL OS SER , M. D.
SO L O MAN S HA H, M. D.
WA SE EM AZIZ , M. D.
DIP L O M A TE S OF THE A M ER ICA N BO AR D OF IN TE R N AL M ED ICIN E AN D
DIP L O M A TE S OF THE S UBS PEC IAL T Y BO AR D O F GA S TR OEN TER OL OG Y
www.gastromedva.com
3620 JOSEPH SIEWICK DR, STE 307
FAIRFAX, VIRGINIA 22033
(703) 281-1023
11440 COMMERCE PARK DRIVE, STE LL3
RESTON, VIRGINIA 20191
(703) 281-1023
COLORECTAL CANCER SCREENING and EGD
OPEN ACCESS Packet
After careful medical assessment, your healthcare provider has recommended that you have a
colonoscopy. Colon cancer is the second leading cause of cancer death in the United States, and
colonoscopy is the recommended screening test for any patient over the age of 50. For those with
a family history of colon cancer or polyps, colonoscopy is recommended at age 40 or 10 years
before the age that family member was diagnosed.
This webpage and downloadable packet are designed to effectively and efficiently guide you
through the scheduling process for your colonoscopy procedure without an office visit.
You are invited to proceed with Open Access Colonoscopy if you meet the following criteria:
 Colonoscopy is for routine screening, history of polyps/colon cancer, a family history of
colon neoplasm, or routine colonoscopy for inflammatory bowel disease in remission
 You have NO active symptoms (abdominal pain, a change in bowel habits, etc.)
 You do NOT have severe pulmonary or cardiac disease
If you believe that Open Access Colonoscopy is the right option for you, please download the
attached packet and complete it, following the directions. You may send the packet (complete
with your insurance card and photo ID) to our office via mail, email, or fax. Please allow up to
five business days for our office to review your packet and pre-certify your exam. After our
medical staff reviews your paperwork, we reserve the right to require an office visit prior to
proceeding with your colonoscopy. If that is the case, our scheduling staff will inform you of the
reason for your office visit when they call. Once your paperwork is cleared by the medical staff,
we will call you to schedule your colonoscopy. If you have not heard from our office within two
weeks, please call us at 703-281-1023.
When your colonoscopy is scheduled, we will mail you a packet with your preparation prescription
and all instructions. If you have any questions, please do not hesitate to call us.
If you do not meet the criteria for Open Access Colonoscopy, or wish to have an office visit with a
member of our medical staff prior to your procedure, please call the office at 703-281-1023, option
3, to schedule an appointment.
We look forward to working with you.
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
M YR ON S H OH AM, M .D .
L EON A R D S F I SC HER , M .D .
R . A L L EN BL OS SER , M. D.
SO L O MAN S HA H, M. D.
WA SE EM AZIZ , M. D.
DIP L O M A TE S OF THE A M ER ICA N BO AR D OF IN TE R N AL M ED ICIN E AN D
DIP L O M A TE S OF THE S UBS PEC IAL T Y BO AR D O F GA S TR OEN TER OL OG Y
www.gastromedva.com
11440 COMMERCE PARK DRIVE, STE LL3
RESTON, VIRGINIA 20191
(703) 281-1023
3620 JOSEPH SIEWICK DR, STE 307
FAIRFAX, VIRGINIA 22033
(703) 281-1023
Please complete and return the following
6 pages of this packet:
1.
2.
3.
4.
5.
6.
Cover Sheet and Check List
Patient Demographics
HIPAA Consent
Colonoscopy Consent
Scheduling Consent
Medical History Form
In addition to the forms in this packet,
please provide our office with:



An enlarged copy of your insurance card, front
and back
An enlarged copy of your driver’s license or
photo I.D.
Insurance referral if required
This information is needed prior to your colonoscopy procedure. Open Access allows for
your colonoscopy or EGD without having to be seen in the office first. Therefore it is
imperative that all forms are submitted at once.
We cannot schedule your procedure if any forms or I.D. cards are missing.
You may submit your forms in one of 4 ways:
1.
3.
Mail:
Gastrointestinal Medicine Associates
3620 Joseph Siewick Drive Ste 307
Fairfax, Virginia 22033
Attn: Open Access
2.
Fax: 703-620-2331
In Person:
Monday-Friday, 9am-4pm
Fairfax office
4.
Email: openaccess@gastromedva.com
Please be advised that you will have your procedure within 30 days.
Please read all instructions and information contained in this packet thoroughly.
You will receive your preparation instructions at the time you are scheduled.
If you have any questions or concerns regarding this procedure, please call the office at 703-281-1023
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
M YR ON S H OH AM, M .D .
L EON A R D S F I SC HER , M .D .
R . A L L EN BL OS SER , M. D.
SO L O MAN S HA H, M. D.
WA SE EM AZIZ , M. D.
DIP L O M A TE S OF THE A M ER ICA N BO AR D OF IN TE R N AL M ED ICIN E AN D
DIP L O M A TE S OF THE S UBS PEC IAL T Y BO AR D O F GA S TR OEN TER OL OG Y
www.gastromedva.com
11440 COMMERCE PARK DRIVE, STE LL3
RESTON, VIRGINIA 20191
(703) 281-1023
3620 JOSEPH SIEWICK DR, STE 307
FAIRFAX, VIRGINIA 22033
(703) 281-1023
OPEN ACCESS COLONOSCOPY and EGD COVER SHEET
Patient Name:
Number of pages including this cover sheet:
Check List
Cover Sheet
Demographic Information
Signed HIPAA Consent
Signed Colonoscopy and or EGD consent
Completed and Signed Procedure Scheduling Form
Your Completed Medical History Form (2 pages)
Photo ID
Insurance Card (front and back)
Referral from your primary care physician if required by your insurance
All the information contained in this packet is complete and true to my knowledge.
Patient Signature
Date
What is the best way to contact you?
___ Email
___ Cell
___ Work
___ Home
What time of day should we contact you?
___Morning
___ Afternoon
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
Patient Demographic Information
Patient Full Name:
Address:
City:
State:
Home #
Zip code:
Date of Birth:
Work #
Male
Cell #
Female
Age:
Marital Status:
S
M
D
W
Social Security #
Email Address:
Employer:
Occupation:
Emergency Contact:
Phone #
Primary Care Physician:
City, State:
Referring Physician:
City, State:
Primary Insurance Information:
Insurance Name:
Identification #
Group #
Policy Holder Name:
Relationship to Patient:
Holder’s Date of Birth:
Social Security #
Secondary Insurance Information:
Insurance Name:
Identification #
Group #
Policy Holder Name:
Relationship to Patient:
Holder’s Date of Birth:
Social Security #
PAYMENT POLICY
All professional services rendered are charged to the patient. Necessary forms will be completed to help expedite insurance carrier payments. However, the patient is
responsible for all fees, regardless of insurance coverage. It is also customary to pay for services when rendered, unless other arrangements have been made in
advance with our office. In the event my account is turned over to an attorney for collections, I will pay any fee / costs incurred during the collection process
INSURANCE AUTHORIZATION AND ASSIGNMENT
I hereby authorize Gastrointestinal Medicine Associates, P.C. to furnish information to insurance carriers (including Medicare / Medigap) concerning my illness and
treatments and I hereby assign to the physician(s) all payments for medical services rendered to myself or my dependents. I understand that I am responsible for any
amount not covered by insurance(s).
I understand I am responsible for a charge of $50.00 for missed appointments without at least 24 hour prior cancellation
notice; a $15.00 fee if I don’t pay my co-pay at the time of my visit.
I verify that the information provided above is correct.
Signature of Patient
Date
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
HIPAA Consent
Consent for Release and Use of Confidential Information and Acknowledgement of
Notice of Privacy Practices
I
hereby give my consent to
(name of patient or authorized agent)
Gastrointestinal Medicine Associates, P.C. (GMA) to use or disclose, for the purpose of carrying out treatment,
payment, or health care operations, all information contained in the patient record of
(name of patient)
I acknowledge the review and / or receipt of the physician’s Notice of Privacy Practices. The Notice of Privacy
Practice provides detailed information about how the practice may use and disclose my confidential
information. I understand that the physician has reserved a right to change his or privacy practices that are
described in the Notice. I also understand that a copy of a revised Notice will be available to me upon a written
request to the Privacy Officer.
I understand that this consent is valid until it is revoked by me. I understand that I may revoke this consent at
any time by giving written notice of my desire to do so, to the physician. I also understand that I will not be
able to revoke this consent in cases where the physician has already relied on it to use or disclose my health
information. Written revocation of consent must be sent to the physician’s office.
I understand that I have the right to request that the practice restricts how my individual identifiable health
information is used and / or disclosed to carry out treatment, payment or health operations. I understand the
practice does not have to agree to such restrictions, but that once such restrictions are agreed to, the practice
and their agents must adhere to such restrictions.
I authorize GMA that family members may have access to my records or to act on my behalf in the
coordination of my care. (Please choose one)
YES
NO
If yes, only those family members listed below may have access to my records.
Signed
If not the patient, please specify your relationship to the patient:
Date:
GASTROINTESTINAL MEDICINE ASSOCIATES
Patient Medical History
Patient Full Name
DOB
/
Date Form Completed
/
Male
Female
PCP phone
3
.
-
-
(Office use only)
Dx:
Weight
Height
1
.
/
Insurance
Primary Care Physician
Allergies
/
2.
Are you currently experiencing any of these
symptoms? Please check all that apply
Personal Medical History
Please check all that apply
Abdominal pain
Hypertension/High Blood Pressure
Change in bowel habits
Diarrhea
Constipation
Rectal bleeding
Mucus in stool
Loss of appetite
Unintentional weight loss
Gout
Heartburn and/or indigestion
Problems swallowing/Food getting stuck
NONE OF THE ABOVE
Coronary Artery Disease
Cancer (Type)
Sleep Apnea or CPAP use
Asthma/ COPD
Diabetes
Seizures
Bleeding problems
Other medical issues
NONE OF THE ABOVE
Current Medications
Please list your medications and dosages for each. Check those that apply and/or attach your own list.
Include over the counter medications and supplements.
Medication Name
Dosage
Medication Name
Dosage





Plavix/Effient
Coumadin/Warfarin
Aspirin
NSAIDS (Ibuprofen,
Naprosyn, etc.)
4
.
Social History
Please check all that apply
Tobacco
How
Much?
Alcohol
How
Much?
Caffeine
How
Much?
5.
Family History
Please check all that apply.
Please indicate family member(s) and age of diagnosis.
Colon Cancer
Colon Polyps
Stomach Cancer
Esophageal Cancer
Barrett’s Esophagus
Crohn’s Disease
Ulcerative Colitis
Gallbladder Disease
Peptic Ulcer Disease
Gynecological Cancer
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
M YR ON S H OH AM, M .D .
L EON A R D S F I SC HER , M .D .
R . A L L EN BL OS SER , M. D.
SO L O MAN S HA H, M. D.
WA SE EM AZIZ , M. D.
DIP L O M A TE S OF THE A M ER ICA N BO AR D OF IN TE R N AL M ED ICIN E AN D
DIP L O M A TE S OF THE S UBS PEC IAL T Y BO AR D O F GA S TR OEN TER OL OG Y
www.gastromedva.com
11440 COMMERCE PARK DRIVE, STE LL3
RESTON, VIRGINIA 20191
(703) 281-1023
3620 JOSEPH SIEWICK DR, STE 307
FAIRFAX, VIRGINIA 22033
(703) 281-1023
When was your last physical exam?
Was it
normal
abnormal? If abnormal why?
/
/
Please provide us with your pharmacy information below, we may send your preparation directly to your
pharmacy.
Name:
Address:
Phone Number:
The rest of this page intentionally left blank.
GASTROINTESTINAL MEDICINE ASSOCIATES
Patient Medical History
Name___________________ DOB_______
6.
Procedure History
When was your last procedure? And what were the results?
Colonoscopy
/
/
Upper Endoscopy (EGD)
/
/
Flexible Sigmoidoscopy
/
/
I have never had any endoscopies
7.
Normal or
Normal or
Normal or
Surgical History or Hospitalizations
None
Please list all surgeries/hospitalizations dates and reasons
/
/
/
/
/
/
/
/
The medical information provided is complete and true to my knowledge.
_________________________
Patient Signature
_________________________
Date
For Office Use Only
1. BMI:______________SLEEP APNEA:
Yes No
2. Patient scheduled for open access colonoscopy? Yes No, Why not __________________________
3. Reason for procedure:
CRCS
FHx ______________
h/o Polyps
h/o CRC
other_____________
4.
STANDARD PREP
Other ___________________________
5.
FOH
RHC
ASC
GCV
6.
MAS
LSF
RAB
SSH
WIA
7. Patient needs office visit for: ____________________________________________________________
MLP Signature _________________________________ Date ________________________
MD Use Only
History reviewed and agreed
VS: T________ P________ R________ BP ________
GEN:
WDWN in NAD
abnormal ____________________
EYES:
EOMI, anicteric
abnormal ____________________
CHEST:
CTAB w/r/r
abnormal ____________________
COR:
RRR m/r/g
abnormal ____________________
ABD:
NABS soft, NT/ND, g/r
abnormal ____________________
EXT:
c/c/e
abnormal ____________________
MD Signature _________________________________ Date ________________________
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
M YR ON S H OH AM, M .D .
L EON A R D S F I SC HER , M .D .
R . A L L EN BL OS SER , M. D.
SO L O MAN S HA H, M. D.
WA SE EM AZIZ , M. D.
DIP L O M A TE S OF THE A M ER ICA N BO AR D OF IN TE R N AL M ED ICIN E AN D
DIP L O M A TE S OF THE S UBS PEC IAL T Y BO AR D O F GA S TR OEN TER OL OG Y
www.gastromedva.com
11440 COMMERCE PARK DRIVE, STE LL3
RESTON, VIRGINIA 20191
(703) 281-1023
3620 JOSEPH SIEWICK DR, STE 307
FAIRFAX, VIRGINIA 22033
(703) 281-1023
COLONOSCOPY INFORMATION AND CONSENT
Colonoscopy is an endoscopic examination of the colon. This procedure is usually done as outpatient
and involves the insertion of a flexible scope instrument into the rectum and the entire colon.
Colonoscopy may be only diagnostic, or it may be therapeutic, in which case a polyp may be removed
or a biopsy may be taken, or a bleed site cauterized using an electrical current.
PREPARATION: Please discontinue anti-inflammatory products, and iron one week prior to your procedure date.
Please continue all other medications until the day before your procedure. (Please consult with your doctor
concerning any medication taken in the morning, especially insulin, blood pressure, seizure, or cardiac medications,
as they may be allowed.) Please follow the preparation instructions given to you for the day before.
SEDATION: Preoperative medications include an intravenous injection of sedation medication administered by an
anesthesiologist to insure the patient is relaxed and comfortable. General anesthesia is not required. Because of the
sedation, the patient WILL NOT be allowed to drive him or herself home. Transportation home must be arranged
with another person and not by taxi (unless accompanied by an adult.)
RISKS: Serious complications of colonoscopy such as intestinal bleeding and/or perforation are infrequent. The
risks are slightly greater in the elderly and in individuals who have had multiple abdominal operations, a history of
abdominal infections, or prior radiation therapy. Other complications include drug reaction from the sedative
medications (such as irritation at the IV site, severe allergic reactions to the medicine), prolonged abdominal pain,
prolonged lethargy, etc. This list is not inclusive of all possible risks and complications.
Risks of Colonoscopy
Bleeding
Perforation
Diagnostic
Less than 1%
Less than 1%
Therapeutic
1.5-2%
Less than 1%
RESULTS: The results of the colonoscopy and/or biopsies will be sent to you and your referring physician in
approximately 4-6 weeks. We will provide you with the results of your procedure via a letter or by arranging an
office visit for follow-up. If any serious abnormality is identified you will receive a phone call as soon as possible.
(Please do not call the office for results by phone.)
CONSENT: I have read the above information and understand the indications for a colonoscopy, its potential risks,
its potential benefits, and potential complications. I consent to the taking and reproduction of any photographs
of the procedure for professional purpose. I hereby authorize and permit
M.D.
and whomever he may designate as his assistant, to perform upon me the procedure of colonoscopy.
I acknowledge that I have received preparation instructions for this procedure.
Print Patient Name
Witness
Signature (Patient or legal guardian)
Date
(Initials)
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
M YR ON S H OH AM, M .D .
L EON A R D S F I SC HER , M .D .
R . A L L EN BL OS SER , M. D.
SO L O MAN S HA H, M. D.
WA SE EM AZIZ , M. D.
DIP L O M A TE S OF THE A M ER ICA N BO AR D OF IN TE R N AL M ED ICIN E AN D
DIP L O M A TE S OF THE S UBS PEC IAL T Y BO AR D O F GA S TR OEN TER OL OG Y
www.gastromedva.com
11440 COMMERCE PARK DRIVE, STE LL3
RESTON, VIRGINIA 20191
(703) 281-1023
3620 JOSEPH SIEWICK DR, STE 307
FAIRFAX, VIRGINIA 22033
(703) 281-1023
PROCEDURE SCHEDULING FORM
PLEASE READ THIS FORM CAREFULLY AND COMPLETE ALL SECTIONS
Are you an insulin-dependant diabetic? (If yes, A.M appointments only):
YES
NO
If you need to schedule, reschedule or cancel any procedures please call us at 703-281-1023 and press the option for the
procedure coordinator. Please DO NOT call the facility or leave messages concerning procedure scheduling on the nurses’
voicemail. Your call will be returned by our coordinator within 48 hours.
I give my permission for procedure appointment information (not results) to be left:
(May check more than one)
Left on home answering machine
Left with spouse/immediate family
Left on cell phone voicemail
Cell phone #
Left on work voicemail
Left with assistant
Due to unavoidable circumstances, the time of my procedure is subject to change due to cancellation and/or emergencies. I
understand this is infrequent but may happen. If a change in my procedure time is necessary I will be notified immediately.
I understand that I must notify Gastrointestinal Medicine Associates, P.C. at 703-281-1023 ext. 106 if I wish to cancel my
procedure for any non-emergency reason or if my insurance has changed.
If I fail to do this within FIVE (5) BUSINESS DAYS of my scheduled time I will be charged $250.00.
I understand that work is not an emergency. I understand that if I call to reschedule within two (2) business days of my
procedure I will be charged $100.00.
I understand that I cannot drive myself home following my procedure, and that I must be accompanied by someone who will be
responsible for taking me home. The use of a taxi or public transportation to go home following my procedure is unacceptable
unless I am accompanied by an adult.
I understand that I will be responsible for all costs associated with my procedure and that I may receive bills from the facility,
the doctor, anesthesia and pathology.
I understand that I am able to call my insurance for coverage information and my out of pocket costs.
Due to insurance and healthcare liabilities, I understand that I will need to repeat my office
consultation if I do not complete my procedure within 6 months of my last visit.
By signing this form I have read and agree to all the above information.
I understand I can not be scheduled if I do not sign this form.
Print Patient Name
Witness
Signature (Patient or legal guardian)
Date
GASTROINTESTINAL MEDICINE ASSOCIATES, P.C.
M YR ON S H OH AM, M .D .
L EON A R D S F I SC HER , M .D .
R . A L L EN BL OS SER , M. D.
SO L O MAN S HA H, M. D.
WA SE EM AZIZ , M. D.
DIP L O M A TE S OF THE A M ER ICA N BO AR D OF IN TE R N AL M ED ICIN E AN D
DIP L O M A TE S OF THE S UBS PEC IAL T Y BO AR D O F GA S TR OEN TER OL OG Y
www.gastromedva.com
3620 JOSEPH SIEWICK DR, STE 307
FAIRFAX, VIRGINIA 22033
(703) 281-1023
11440 COMMERCE PARK DRIVE, STE LL3
RESTON, VIRGINIA 20191
(703) 281-1023
UPPER GASTROINTESTINAL ENDOSCOPY INFORMATION AND CONSENT
An upper gastrointestinal endoscopy (EGD, gastroscopy) is an examination which enables direct inspection
of the esophagus, stomach, and duodenum. There are no x-rays involved with this procedure. A flexible
gastroscope (a tube containing light, lens, and biopsy channel) is used for this procedure through which
biopsies can be obtained. Neither the Endoscopy nor the biopsy is associated with any pain.
PREPARATION: Unless otherwise stated, we recommend that you do not eat or drink any food or liquid from
midnight the evening prior to the procedure. Please discontinue all aspirin, aspirin containing products, and iron one
week prior to your procedure. (Please consult with your doctor concerning any medication taken in the morning,
especially insulin, blood pressure, seizure, or cardiac medications, as they may be allowed.)
SEDATION: Preoperative medications include an intravenous injection of sedation medication administered by an
anesthesiologist to insure the patient is relaxed and comfortable. General anesthesia is not required. Because of the
sedation, the patient WILL NOT be allowed to drive him or herself home. Transportation home must be arranged
with another person and not by taxi (unless accompanied by an adult.)
RISKS: There are few risks related to the EGD. Risks of bleeding, perforation, and aspiration of gastric contents into
the lung are exceedingly rare, but are somewhat more common in elderly patients. The other significant risks include
side effects from medication, such as over sedation or severe allergic reactions, and possible irritation of the vein at
the IV site called phlebitis.
RESULTS: The results of the EGD and/or biopsies will be sent to you and your referring physician in approximately
4-6 weeks. We will provide you with the results of your procedure via a letter or by arranging an office visit for
follow-up. If any serious abnormality is identified you will receive a phone call as soon as possible.
(Please do not call the office for results by phone.)
CONSENT: I have read the above information and understand the indications for an EGD, its potential risks, its
potential benefits, and potential complications. I consent to the taking and reproduction of any
photographs of the procedure for professional purpose. I hereby authorize and permit
M.D.
and whomever he may designate as his assistant, to perform upon me the procedure of EGD.
I acknowledge that I have received preparation instructions for this procedure.
Print Patient Name
Signature
Witness
Date
(Initials)