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Pre-Screen Form

Memorial Endoscopy Center (MEC) realizes that your time is important and some of our patients may wish to proceed with a colonoscopy for colon cancer screening without a preliminary visit to the physician’s office (so called open-access colonoscopy). To accommodate these patients we have provided the following checklist to determine if you are a candidate for screening colonoscopy under this circumstance. Please take a moment to review and answer all the following items:

If you would prefer, print this page, complete the information and fax to 713-465-4029.

We ask you to remember that eligible patients for this arrangement are generally healthy patients without major medical illnesses. If you have checked ALL the above items you will be considered for colonoscopy without a prior physician visit. Please keep in mind that, rarely, the physician that examines you prior to your procedure may discover other circumstances that could change your candidacy for open-access colonoscopy.

When you make your appointment for your procedure our staff will obtain appropriate insurance information and verification to ensure your plan provides for this screening. Some plans (HMOs’ and some PPOs’) will require pre-certification and/or a referral form your primary care physician.

Should you not meet criteria as listed above or feel more comfortable with an office visit prior to your procedure, please ask our staff to arrange an appointment with one of our doctors. Visits can usually be arranged within a two week period.

Call 713-979-3812 to schedule your CRC Screening or make a doctor’s appointment to prepare for your procedure. The Memorial Endoscopy Center is conveniently located on Campbell (1233 Campbell) one mile north of the Katy Freeway.