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Open Access Colonoscopy - Patient Information


Open Access Colonoscopy allows healthy patients, without exclusion criteria, to receive a screening colonoscopy without an initial office visit.

Colonoscopy screening is a test for early diagnosis of common cancers before symptoms develop.

Colorectal cancer is the second leading cause of cancer related deaths a 5 - 6 percent lifetime risk.

The current recommendation for colon cancer screening by the American Cancer Society is a colonoscopy starting at the age of 45. Future examinations are planned based on the findings.


Exclusion criteria list includes:

• Anticoagulants (blood thinner) / Antiplatelets / clotting diathesis
• Multiple or unstable co-morbidities (having one or more additional  diseases)

o Unstable cardiac disease, pacer/defibrillator, endocarditis, recent myocardial infarction (MI)

o Steroid-dependent pulmonary disease, sleep apnea, or use of a CPAP

o Renal distress, dialysis

o Neurologic disorders

• Unstable cardiac disease, pacer/defibrilator, endocarditis, recent myocardial infarction (MI)
• Oxygen or steriod dependent pulmonary disease, sleep apnea or CPAP
• Renal distress, dialysis
• Neurological disorders
• Extensive abdominal surgery
• GI bleeding, change in bowel movements, weight loss, bleeding
• Chronic narcotic use for pain control
• Insulin dependent diabetes
• Previous problems with anesthesia
• Age > 80
• Overweight


To begin this process, please complete the questionnaire and email to 

Liver Specialists of Texas. LLC

6560 Fannin Street Suite 2050

Houston, Texas 77030



Please allow two weeks for the paperwork to be processed.

Paperwork needs to be filled out in its entirety or it will not be processed.

Please provide a copy of recent lab work.


Patient Name: _____________________________Date of Birth: ________________
Phone: ________________________ Height:________________ Weight: ____________


Primary Care Physician:



GI Symptoms:

o None
o Poor appetite o Bleeding o Polyps / Diverticulosis
o Weight loss o Nausea / vomiting o Change in bowel pattern
o Difficulty swallowing o Abdominal pain o Heartburn


Past Medical History:

o None
o Anemia o Sleep apnea o Seizure o Cancer o Diabetes
o Stroke o Crohn’s disease o Blood clotting problems o DVT / PE o Diverticulitis
o Heart problems o MRSA or VRE o Liver disease / Hepatitis o Hypertension
o Ulcerative colitis o High cholesterol o Polyps o Kidney disease
o Lung problems o Endocarditis o TB


Previous Procedure / Surgical Information:

o EGD / Colonoscopy –


Date: ______________________________________________
o Gastric bypass / Abdominal surgery – Explain: _______________________________________
o Previous surgeries (general, orthopedic, etc) – Explain: _________________________________



Please attach list of medications, vitamins and aspirin products or blood thinners
o Aspirin or aspirin products o Lovenox o Eliquis
o Vitamins o Coumadin (warfarin) o None
o Plavix o Pradaxa o Other
o Xarelto o NSAID (Celebrex, ibuprofen, naproxen,Toradol, Lodine, Indocin)





History: Family / Social 

o Colon cancer o Polyps o Tobacco o Alcohol
Symptoms: o Fever o Bleeding problems o Breathing difficulties
o Chest pain o Lightheadedness / Fainting o None


Patient Signature



Provider Signature