Online Colonoscopy Screening Form

Thank you for your interest in our colonoscopy screening service.

Please fill out the form below, and a representative will contact you at the phone number you provide within two business days to schedule your appointment.

Colonoscopy screenings are performed in the Endoscopy Center at Columbus Regional Health.

First Name

Middle Initial

Last Name

Best Phone Number to Call

Best Time to Call

Morning
Afternoon

Email Address

Gender

Male
Female

Date of Birth

First colonoscopy?

Yes
No

Street Address

City

State

ZIP Code

Name of Insurance

To help us coordinate your procedure, please list your primary care doctor (first and last name).

Provide the city where your doctor's office is located.

How did you hear about this service?

Healthy Tomorrow print magazine
Search engine (Google, Bing, Yahoo, etc.)
Social media (Facebook, Twitter, etc.)
Radio or newspaper
Physician referral
Already familiar with this office
Other

If you selected "other" in the previous question, please provide details.

By clicking “I Accept” below, I am authorizing Columbus Regional Health to forward my personal information documented above to its physician partners for purposes of scheduling colonoscopy-related appointments for myself or a family member.

I Accept

Innovation

Why Columbus Regional Health?

100 Years of Caring

Diversity, Equity & Inclusion

Thank you for your interest in our colonoscopy screening service.

Brad's Story

If you are 45 or older, schedule a screening colonoscopy today