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 $950.
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.

Home > Request an appointment

Request an Appointment

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

» You will be contacted within 1 business day after you submit your request.
» Please ensure that you have read our Nationwide Colonoscopy Program FAQ before submitting a request.
» Please check Appointment Wait Times for your city before submitting a request. For urgent requests, please call our appointment line.
» You can read our Privacy Policy here.

* Indicates a required field

Patient Information

* First Name
* Last Name
* Street Address
* City
* State
* Zip Code
* Date of Birth (MM/DD/YYYY)
* Gender	Female Male
* Do you have a physician referral?	Yes No Don't know

Contact Information

Name (if different from patient name)
* Email Address
* Daytime Phone	(We will only attempt to reach you twice. Please ensure that you are available to answer our call)
Alternate Phone	Ext.

Appointment Information

* Location of Appointment
If Other, Requested City (There is no guarantee ColonoscopyAssist will be able to fulfill your request)
Referring Physician (if applicable)
Referring Physician Phone
Referring Physician Address
*Is the colonoscopy being requested due to symptoms that you are having?	Yes No
If yes, was a colonoscopy recommended by a physician?	Yes No
Please describe the reason for the appointment you are requesting (eg. Cancer screenings, Symptoms etc). You may also request additional procedures like an Upper GI or ask any specific questions that you may have.
Referral Code (if applicable)
* How did you hear about us?

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)

What is the ColonoscopyAssist™ Program About?

Request an Appointment

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