Clinic for Colon & Rectal Surgery, P.A.

• For patients coming to our office for the initial appointment and for patients who have not been to our office in one year or more, copy Forms A, B, C, and D (see below). Please provide requested information on Forms A, B, and D and sign where requested. The signed forms can be mailed to our office or brought to our office at the time of the appointment.

• For patients scheduled for colonoscopy , copy Forms A, B, C, and D. If you have not been to our office in the last one year, please fill out the requested information and return them to our office by mail.

• For patients needing instructions for preparation for colonoscopy , copy one of the following forms; Form F (CoLyte, GoLYTELY, NuLytely Prep) or Form G (HalfLytely Prep).

If there is any confusion about the prep to be used, please contact our office (256-533- 6070).

Also, for patients having colonoscopy, Form E should be reviewed prior to colonoscopy. Your physician will answer any questions you may have concerning colonoscopy prior to the procedure.

All patients should review Form H – Insurance and Other Information.

Click below to download patient forms.*

• A. Patient Information Form
• B. Medical Information Form
• C. Notice of Privacy Practices
• D. Receipt of Notice of Privacy Practices Written Acknowledgement Form
• E. General Information About Colonoscopy
• F. Preparation for Colonoscopy – CoLyte/GoLYTELY/NuLytely Preparation
• G. Preparation for Colonoscopy – HalfLytely Preparation
• H. Insurance and Other Information

*Must have Microsoft Word to view patient forms.