| q |
I understand (if applicable) my insurance company's coverage
policy for this procedure. Typically screening colonoscopy is not covered in individuals under the exact age
of 50 and at average risk (Average risk means no family history of colon polyps or colon cancer or
personal increased risk factors). I agree that if my insurance will not pay for the procedure that
I will be responsible for it. |
| q |
I have no significant medical problems including heart
or lung disease and do not use blood thinners such as coumadin, plavix,
or pletal. |
| q |
I have no gastroenterology-related complaints that usually
require a consultation with Dr. Sarzen, such as
abdominal pain or gastrointestinal bleeding. |
| q |
I am comfortable meeting Dr. Sarzen over the phone and then again in person for a brief time (2-3 minutes) immediately prior
to the procedure and do not have special needs or complex questions which are better served
by an office visit. |
| q |
I am able to download necessary forms and instructions over the internet
and fax completed forms back to Dr. Sarzen. |
| q |
I will give Dr. Sarzen's office my cell number or other dependable phone
number so his staff can easily reach me so that
they can discuss instructions with me and so that
I can have a phone interview with Dr. Sarzen. |
| q |
I agree to stop all blood thinners including: aspirin products 7 days
prior to exam, NSAIDS 3 days prior to exam, and
Vitamin E 5 days prior to exam, and I agree that
if I am unclear about what these are, I will discuss
this with Dr. Sarzen's staff. |
| q |
Since I have decided to forgo the pre- and post-colonoscopy office visits,
I agree to play an active role in following up on
the results of my colonoscopy. If I do not receive
a letter from Dr. Sarzen containing a summary and
recommendations, I will contact his office. |
| q |
I agree to pay $25, non-refundable, via credit
card for the telephone consultation. |
