What is the ColonoscopyAssist Program About?

  • The ColonoscopyAssist program provides colonoscopy screenings and colon cancer support for the underinsured community.
  • Colonoscopy screenings are provided nationwide at an all-inclusive discounted rate of $1075.
  • Screenings are provided completely free of charge in certain regions where funding is available.
  • Specialized support and help is provided for patients diagnosed with colon cancer.

Request an Appointment

  

To request an appointment, please fill out the form below.

» Upon submission of this form, you will be able to select your facility and physician via our interactive map. You will also be able to complete your scheduling forms.
» Please ensure that you have read our Nationwide Colonoscopy Program FAQ before submitting a request.
» If you intend to utilize our payment plan options, please apply for a payment plan.
» You can read our Privacy Policy here.

* Indicates a required field

 
Patient Information
* Gender
* Do you have a physician referral?   Don't know
Contact Information
 
(We will only attempt to reach you twice. Please ensure that you are available to answer our call)
Appointment Information
*Is the colonoscopy being requested due to symptoms that you are having?
If yes, was a colonoscopy recommended by a physician?

 

The use or transmittal of this form does not create a physician-patient relationship. More information regarding the confidentiality of this request can be found in our Privacy Policy.

  (Form may take up to 60 seconds to submit)