Colorado heart - body - lung - colon - imaging and scanning - colon cancer screening - virtual colonoscopy


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Call 303-433-8800
or e-mail
Street address

Appointment Form

Please fill out this online form and we will be in touch shortly.
* fields must be filled in.

*Name:

*Gender:

M F

*Birth Date:

- mm/dd/yy

*Weight:

Work phone:

*Home phone:

Best to reach at:

Work
Home

E-mail:

*Please select from
the following:

Heart Scan (CAS)
Lung Scan (especially for smokers)
Heart and Lung Scan
Colon Scan (EB Colonography - "Virtual")
Bone Mineral Density Scan (QCT)

Referring Physician:

*required for lung scan / virtual colonscopy

*Reason for scan:

Self-referring preventive
Physician-referring preventive
Physician-referring diagnostic

*Family history :

Heart Disease:	Yes No
Colon Cancer:	Yes No

Are you a ... Smoker Nonsmoker

Are you having any current symptoms:
Chest pain Shortness of breath Abdominal pain Rectal bleeding Recent change in weight
Have you had: (Please answer carefully)
a prior history of cancer a prior heart attack bypass surgery an angioplasty or stent placement

*Office Preference:

Downtown (Diamond Hill):
2490 West 26th Avenue
#110-A
Denver, Colorado 80211

Cherry Creek:
201 Columbine
Denver, Colorado 80206

*Requested Scan Date:

- mm/dd/yy

Requested Time:

AM PM

*How did you
hear about us?

Radio
TV
Newspaper
Physician
Family
Friend