Procedure Scheduling Form- Please Read All Instructions Below Before Submission.
If you are are an established patient with our practice and it is time to schedule your procedure, you have come to the right place!!

OFFICE VISITS ARE REQUIRED BEFORE SCHEDULING A PROCEDURE IF ANY OF THE FOLLOWING APPLY:

1. If you have not been seen in our practice within the last three (3) years.
2. It has been over three (3) years since your last consultation in office with your DLDC physician.
3. You are having acute symptoms, such as: fever, abdominal pain or rectal bleeding
4. You have had a major change in your health status, such as: a heart attack, stroke, or seizure - all since your last in office consultation visit.

If either of the four (4) above scenarios apply to you, please contact our office scheduling department at 281-453-2050 or scheduling@gimed.net to schedule an office visit consultation with your DLDC physician. Unfortunately, we will not be able to schedule your procedure until you have been evaluated by your DLDC Physician. Completing this form will only delay your office visit scheduling.

PROCEDURE SCHEDULING PROCESS AND QUESTIONNAIRE:
If you are not having any symptoms or have any changes in your health since your last visit, You can begin the procedure scheduling process electronically by providing the requested information below.

Once you submit the information below, your chart will be audited and clinically updated. Your procedure will then be scheduled and you will receive a confirmation email advising you of your scheduled date and arrival time. This review/verify/update/clinical audit of your medical record and insurance can take several days to complete, so your patience is very much appreciated. This process is billable as a nurse level consultation visit.

Additionally, an email will be sent to you within the week of your scheduled procedure date that contains your detailed procedure instructions and prescription information.

Dr. Reddy, Dr. Hamat, Dr. Shah and Dr. Tesfay are available at various times Monday through Friday. Please provide 1-2 dates of availability for these physicians and you will be scheduled as requested in accordance with their availability. If your dates do not align with your physicians availability, you will be scheduled on the closest available date to the preferred dates submitted.

Please note: If you are due for an Upper Endoscopy and Colonoscopy, these procedures will be scheduled on two separate dates.

Please email Lori Young, Procedure Recall Coordinator with any additional questions at lyoung@gimed.net.

Thank you for allowing our practice the opportunity to provide you with ongoing care for your gastrointestinal needs. We appreciate you!
Email address *
Untitled Title
Are you currently having any of the following issues: fever, nausea, vomiting, chest pain, shortness of breath, difficulty laying flat, abdominal pain, abnormal change in bowel movements, or rectal pain or bleeding? *
Has there been a major change in your health status (i.e. Stroke, Heart Attack, Pneumonia, Seizure, Cancer, Major Surgery or New Diagnosis Of Cardiac Condition(s)) since your last visit with our practice? *
Does your insurance require a referral? *
Patient First and Last Name *
Primary Care/Family Physician (Full Name & Phone #) *
Patient Date of Birth *
Age *
Sex *
Complete Mailing Address (Please include Street, City, State and Zip code) *
Home Phone # *
Cell Phone # *
Work Phone # *
Primary Insurance Company *
Primary Insurance Company Claims Address (See back of card) *
Primary Insurance Phone # *
Primary Insurance Policy ID Number *
Primary Insurance Group Number *
Secondary Insurance Name (Enter NA if None) *
Secondary Insurance Claims Address (Enter NA if None) *
Secondary Insurance Phone Number (Enter NA if None) *
Secondary Insurance Policy ID Number (Enter NA if None) *
Secondary Insurance Group Number (Enter NA if None) *
Patients Email Address *
Preferred LOCAL Pharmacy Name & Phone Number *
Height *
Weight *
Please LIST all Current Medications, Including Over the Counter & Herbal Supplements (MUST include complete name with dosage and frequency of use) *Failure to provide a complete list of your medications in this section will delay the scheduling process.- "On File" is an invalid response. *
Please LIST any and all medical conditions you have been diagnosed with , f you are taking ANY medications, you must list the condition in which you take the medication for in this section. *Failure to provide a complete list of your medical conditions in this section will delay the scheduling process.- "On File" is an invalid response. *
Medication Allergies (Enter NKDA if No Known Drug Allergies) *
Other Allergies (Non-Medication) *
Do you currently use Prescription Blood Thinning Medication? *
If Yes, How long have you been on Prescription Blood Thinning Medication? (Enter NA if this does not apply to you) *
Are you supplemental Oxygen Dependent? *
Are you Dialysis Dependent? *
Do you have a Cardiac Pacemaker or Defibrillator Implant? *
Have you been diagnosed with Organ Failure? *
Do you have Sleep Apnea confirmed via sleep study? *
Do you use a CPAP or BiPAP? (Please specify which - If none please mark NA) *
Are you Walker or Wheelchair Dependent? *
If you answered YES to any of the above questions, Please provide a brief summary of the exact condition, how long you have had the condition, as well as any treating physicians. (If none please mark NA) *
Have you ever been hospitalized for any conditions other than surgery? (Please provide condition hospitalized for and approx. dates)"On File" is an invalid response. *
Have you had any surgeries? (Please provide specific surgical procedure and approx. dates)"On File" is an invalid response. *
Any Family history of chronic medical conditions or any type of cancers? (Please advise who and which type of condition)"On File" is an invalid response. *
Any Personal or Family history of gastric cancer, colon polyps or colon cancer? (Please specify who, which type and age of patient when diagnosed (approx age is ok for family members)."On File" is an invalid response. *
Preferred Date(s) to be scheduled, please provide at least 2 dates of availability as well as any dates that you are unavailable. Please be advised, If you are due for an Upper Endoscopy and Colonoscopy, these procedures will be scheduled on two separate dates. *If your dates do not align with your physicians availability, you will be scheduled on the closest available date to the preferred dates submitted. *
I affirm ,with my electronic signature below, I have provided a complete list of my current and past medical diagnosis/conditions/surgeries along with a complete list of my prescription medication as requested above. I understand all information provided will be reviewed by my physician and designated medical staff for medical clearance purposes for the endoscopic procedure (Upper Endoscopy and/or Colonoscopy) that has been ordered. This process is classified as a virtual office visit and is billable as a nurse level consultation visit. I understand that this process can take several days to complete, failure to provide my complete medical history and medications may result in the inability to schedule or cancellation of my procedure. I understand that during the audit process it may be found that an in office consultation visit is required prior to scheduling, if an office visit is required with the physician I will be contacted directly by the office visit scheduling department (281-453-2050). *
Completion of "Captcha" questions are required, if prompted.
Once submit button is clicked and "Captcha" questions are answered a complete copy of your responses will be emailed to the email address you provided. This is confirmation your submission was transmitted to our office successfully. If you do not receive an email copy of your answers, it was not submitted to our office.
A copy of your responses will be emailed to the address you provided.
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