Forms for Endoscopy Procedures

Gather and Complete the Following Forms and Bring Them With You

• Health History Form
• Patient Home Medication List: If you are unsure of the names, check the original pharmacy container, which will include the dosage and how often you should take the medication. Be sure to include this information on the Medication List. In addition, record the last time you took each medication with the date and time. Be sure to include any allergies you have to medications, foods, latex, or x-ray contrast dye.
• If you have a Health Care Proxy or Living Will, please bring a copy with you. Learn more about Assigning a Health Care Proxy and download the New York Health Care Proxy form.

• Your health insurance cards
• Any x-ray films requested by you doctor