Patient Forms (in English & Spanish)
We are pleased to offer an online version of our required office forms, to expedite the admissions process for your upcoming office visit and/or pending procedure at the Winchester Endoscopy Center
Please review and complete the following before your arrival, signing where indicated. Please call us in advance, if you have any questions whatsoever.
Please remember to bring your insurance card and a picture ID when you are checking in at our office.
If you are having a procedure, please read your necessary procedure preparation instructions. You will need to pick-up the prep kit in advance at your pharmacy and allocate time for its use. Some simple dietary modification, in the days before your procedure, is needed.
Obtaining a copy of your medical record form another physicians office, hospital, or our office is easy. To start your request, simply download, print, complete and sign our record request form. This form must be faxed or mailed to our office. If we are obtaining records on your behalf from another provider, please note that it may take up to 30 days to received your records. If you are requesting records from our office, we will attempt to send them to the requested recipient within 5 business days. Please note, unsigned requests cannot be processed.
Click each form to download:
Patient Registration and Release
Release of Medical Records
Formulario de Inscripción/Liberación
Notice of Privacy Practices
La Nota de Practicas de Intimidad
Patient Medication List
Tronco Paciente de Medicina
Colon Prep – Spanish
EGD Prep – Spanish