Patient Medical Data Forms

Patients who wish to participate in the ‘Single-Visit’ program, to include both an initial
consultation and colonoscopy on the same day, may self-refer or be referred by a
physician. Prior to the visit, the Medical Director must confirm that you are suitable for
an out-of-hospital procedure. In order to do this, you are required to submit a completed
Patient Medical Data Form and, in patients that are older than 35, provide a recent
(within 30 days) electrocardiogram (EKG) for review. When the Medical director has
reviewed your form and EKG, and found them to be satisfactory, you will be contacted
by the Clinic to set up your appointment. Instructions for preparing yourself for the
appointment will be given to you. If you are taking a diuretic for blood pressure control,
you will have to obtain a serum potassium level (simple blood test) within 7 days of your
appointment.

To determine if you are suitable for a Single-Visit procedure at the Pezim Clinic, read ‘Am
I medically-suitable for a procedure at the Pezim Clinic?
’.

© Pezim Clinic, Vancouver, British Columbia, Canada