Patient Forms

Here is the paperwork to be completed before you arrive for your procedure. Please complete and submit the Health History Assessment and the Medication List prior to your appointment.

Surgery and Pain Management Forms

Health History and Medications List

GI Patient Forms

If you are scheduling a colonoscopy or upper endoscopy through our Direct Access Endoscopy program, please complete and submit the DAE form below. Once it is submitted, you will be contacted by the Harmony Surgery Center to schedule your procedure.

Step 1: Please complete the Direct Access Endoscopy form below:

Direct Access Endoscopy Form

Step 2: After scheduling your GI procedure, Please complete and submit the Health History Assessment and the Medication List prior to your appointment.

Health History and Medications List

Step 3: Please select the prep instructions below based on the procedure you are having: (Please disregard this step if you are having your prep instructions delivered to you in a different manner – your scheduler will go over this with you.)

Colonoscopy:

Magnesium Citrate

Suprep

Movi Prep

GoLytely

Flexible Sigmoidoscopy

Upper Endoscopy:

Upper Endoscopy