At Chevy Chase Endoscopy Center, your time is as valuable to us as it is to you. That’s why we provide online access to a variety of forms that patients may complete before their visit. The following documents will help us expedite the check-in process for your appointment.
Please review the following forms if you are a new patient at Chevy Chase Endoscopy Center. On the day of your procedure, you will be asked to sign these forms in the presence of clinical staff:
- Medical History Form
- Colonoscopy Consent Form
- EGD Consent Form
- Flexible Sigmoidoscopy Consent Form
- Multiple Authorization Form
- Colonoscopy Information Brochure
- Colonoscopy Checklist
- EGD Brochure
- CMS Brochure
- Extended Prep for your Colonoscopy Instructions
- Miralax Prep Instructions
- MoviPrep Instructions
- Patient Rights and Responsibilities
- Additional Information about your Procedure
- Important Questions for your Insurance Carrier before your Colonoscopy
- CDC Prep Kit for Colonoscopy
- Clenpiq Prep for Colonoscopy
- Osmo Prep Kit for Colonoscopy
- Peg Prep Kit for Colonoscopy
- Plenvu Prep Kit for Colonoscopy
- Suprep Prep Kit for Colonoscopy
- Upper Endoscopy (EGD) Prep Instructions
*To download prep instructions in Spanish, Korean or Russian, please visit the Capital Digestive Care website and scroll down the page. Contact your physician’s office if you have questions about your prep.
Note: These forms are HIPAA compliant.
Please contact us or call (888) 656-5849 if you have questions.
EGD Patients: You’ll need the CMS Brochure, EGD Brochure and Medical History Form.
Colonoscopy Patients: You’ll need the CMS Brochure, Colonoscopy Brochure and Colonoscopy Checklist.
EGD and Colonoscopy Patients: You’ll need the CMS Brochure, Colonoscopy Brochure and Colonoscopy Checklist.
Chevy Chase Endoscopy respects the right of patients to make informed decisions regarding their care. If you have an Advance Directive, you must bring it to the facility on the day of the procedure.
Information regarding Advance Directives for the State of Maryland can be found here.
You may download an Advance Directive form from Caring Connections here: