To make your visit as smooth as possible, we’ve made our forms available for download below.
Please click on each form title to open or download the file, complete it at home, and bring it to your appointment.
This helps reduce wait time and ensures your information is ready for our staff.
Welcome to Our Patient Forms Center
Post Procedure Discharge Instruction
Cirrhosis Handout
Colonoscopy Prep - 2 day generic bowel prep KEVIMD Standardized
Flex Sig Prep KEVIMD Standardized
IBS Handout
Mechanical Soft Diet
Advanced Directive Acknowledgement
Patient Rights Responsibilities
Colonoscopy Prep - Sutab with Dulcolax KEVIMD Standardized
Gastroparesis Handout
KEVIMD Diverticulitis Diet FACG
Six Food Elimination Diet
Release of Information
EGD Prep KEVIMD Standardized
Colonoscopy Prep - golytely KEVIMD Standardized
Gluten Free Food List
Liver Disease Handout
GERD Handout
New Patient Forms
Patient Registration – demographics, insurance, contacts
Consent for Treatment & HIPAA Acknowledgment
Financial Policy / Assignment of Benefits – billing & payment terms
Records Release (ROI) – obtain/send medical records
Medical History & Medication List
Review of Systems Questionnaire
Prescription Refill Policy
Consent for Minor Treatment
Endoscopy / Procedure Center Forms
Pre-Procedure
Procedure Consent (EGD, Colonoscopy, Polypectomy, Biopsy, etc.)
Anesthesia / Sedation Consent
Pre-Procedure Checklist (NPO, meds, allergies, anticoagulants, devices, OSA)
Pregnancy Test Consent/Decline (when applicable)
Advance Directive / Code Status acknowledgment
Intra-Procedure
[Procedure Safety Checklist (“Time-Out”)]
[Nursing Assessment & Sedation Record]
Compliance & Safety Forms
[OSHA / Bloodborne Pathogen Acknowledgment]
[Incident / Adverse Event Report Form]
[Emergency Transfer Agreement]
[Consent for Photography/Video (if used for education/records)]
Post-Procedure
[Discharge Instructions (tailored to procedure type)]
[Escort Verification (driver/family sign-out)]
[Pathology Release Consent]
CONTACT US
Have questions or need to schedule a visit? Our team is here to listen and provide the support you need for better health.
Contact Us Today
Book Your Appointment Today
Take the first step toward better digestive health. Schedule your visit with Dr. Ezeoke and our dedicated care team today