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For our patients: please note that our virtual colonoscopy procedure involves insertion of a small enema tip into the rectum s

For our patients: Please note that our virtual colonoscopy procedure involves insertion of a small enema tip into the rectum so the colon can be inflated with carbon dioxide to allow visualization. This commonly causes a brief period of discomfort, cramping or the sensation that an “accident” may occur during the inflation sequences. Our CT technologist will guide you all the way. The images acquired during scanning are then sent to an advanced FDA approved workstation for both 2D and 3D reconstruction so that the radiologist can examine the colon and the entire
Please note: If an abnormality is found, it will require a consultation with your
doctor and possible removal by a separate procedure. In many cases, smaller
polyps can be followed over the years without immediate removal. We advise you
visit with your doctor for regular examinations including yearly fecal occult blood
testing (stool blood test) and rectal exam.
You may return to normal eating habits and activities upon completion of the examination. Your results will be mailed to you and your physician. Finally, most patients find the procedure and the prep easy. However, a small minority of patients find either the prep arduous or the procedure more difficult than anticipated, perhaps due to bowel spasms, etc. Although most people will feel well enough to drive home, it is prudent to have a friend “on call” in case you do not feel up to driving.
APPOINTMENT DATE: __________________________

APPOINTMENT TIME: __________________________


Two Days Before Your Exam


Follow your normal meal routine the entire day. In the morning mix the 1st MiraLax packet
with 1 cup of any beverage and then drink. In the afternoon mix the 2nd MiraLax packet with 1
Reconstitute one of the EZ-Cat barium packets with 2 cups water. *Drink 1 cup of reconstituted EZ-Cat barium with each of your two largest meals.

Please remove the Bisacodyl Suppository from the Lo So Prep package and place it in the
refrigerator until the morning of your exam.
The Day Before Your Exam
In the morning mix the 3rd MiraLax packet with 1 cup of any clear beverage and then drink.
Mix and drink the 4th MiraLax packet in the afternoon.
Reconstitute the second EZ-Cat barium packet with 2 cups water. *Drink 1 cup of reconstituted EZ-Cat barium in the morning and one in the
afternoon.

All Day: Ideally, follow a restricted diet consisting of clear liquids: strained fruit juices without
pulp (apple, white grape, lemonade, etc.) water, clear broth or bouillon, coffee or tea, (without
milk or non dairy creamer), Gatorade, carbonated or noncarbonated soft drinks, Kool-aid and
ice Popsicles, plain Jell-O. Drink plenty of fluid throughout the day to avoid dehydration. If you must eat something, you may have plain scrambled eggs or cheese in the morning only. Then liquids only for the rest of the day and evening.
Approx. 5:30 pm – Slowly mix contents of LO-SO PREP packet with 8 ounces water. When
the fizzing stops, drink the entire amount. This product usually produces a bowel movement in 30 minutes to 6 hours. Drink at least 2 more glasses of clear liquids within the next 2 hours.
Approx. 7:30 pm – (2 hours after drinking the LO-SO PREP) Remove the 4 Bisacodyl
tablets and take with 8 ounces of clear liquid. These tablets generally produce bowel movements
Ensure that you have easy access to a restroom. Individual responses to laxatives
vary. Only take medications prescribed by your doctor, no vitamins or
supplements. If you get a headache you may take a liquid or a liquid gel form of
relief, no tablets or capsules.

THE DAY OF YOUR EXAM……

If you have morning medications, bring them with you to take after your exam.
2 hours before exam ………….
Insert suppository into rectum and retain for as long as possible, try for at least 15 minutes. Bowel evacuation usually occurs within 15 to 60 minutes. This is to help eliminate any residual gas or fecal material in the lower portion of the colon. VC PREP EASY CHECK LIST


DATE: ________________________________ (Two Days Before Procedure)

□ 1. Regular meals all day □ 2. Morning: Mix 1st Miralax packet with 1 cup of any beverage & then drink. □ 3. Lunch: Mix EZ-Cat Barium packet with 2 cups water – Drink 1 cup at lunch □ 4. Evening: Drink remaining 1 cup of the EZ-Cat Barium with dinner □ 5. Evening: Mix 2nd Miralax packet with 1 cup of any beverage & then drink. DATE: _________________________________ (Day Before Procedure)
□ 1. Morning: Plain scrambled eggs or some cheese in the morning if you cannot go all day with liquids only. Do not eat anything solid after this. □ 2. No solid food the rest of the day. Drink any clear liquid. Drink a minimum of 64-80 ounces or more throughout the day. □ 3. Morning: Mix 3rd Miralax packet with 1 cup of any beverage & then drink. □ 4. Morning: Mix EZ-Cat Barium packet with 2 cups water – Drink 1 cup now □ 5. Lunch: Mix 4th Miralax packet with 1 cup of any beverage & then drink. □ 6. Lunch: Drink remaining 1 cup EZ-Cat Barium now. □ 7. Approx. 5:30 pm: Mix LO-SO-PREP with 8 ounces water. Drink all. □ 8. Next 2 Hours: Drink at least 2 glasses of any clear liquid. □ 9. Approx. 7:30 pm: Take 4 orange Biscodyl Tablets with 8 ounces clear liquid. □ 10. Put suppository in refrigerator. DATE: ____________________________________ (Day of Procedure)
□ 1. Insert suppository at 6:00 am. (or 2 hours before your exam) If you have any questions, regardless of day or time of day,
Please call Lindsay at 970-481-2944
Patient Information Form

Last Name: _______________ First: _________________________ MI: _____ Marital Status_______
Sex: M / F Birth Date: ____/___/___ Age: __ Height: ____’_____” Weight: _____lbs
SS#_______________________ (THIS IS ONLY USED TO OBTAIN PREVIOUS EXAMS & LABS
AS NEEDED)
Ethnicity: (circle one) Asian Black Caucasian Hispanic Other
To better serve and communicate with you more relevantly we would appreciate your email
address. We keep our email list strictly confidential!

Email address: _________________________________________________________
Mailing Address: ______________________________________________________ Apt / Suite:______
City: __________________ State: ________ ZIP: ___________ Phone: (_______)___________________
Employer_________________________________________________Work #:(_____)_______________
Emergency Contact____________________________ PHONE# _______________________________
HAVE YOU HAD A PREVIOUS CT FOR YOUR ABDOMEN AND OR PELVIS? YES NO
WHERE________________
How did you hear about us:
Virtual Colonoscopy Questionnaire
Reason For Colon Scan: ______________________________________________
Do you have a personal history of Cancer? No Yes
Type:____________________ When:______________ Have you had any previous Abdominal or Colon Surgery? No Yes
If so what?_____________________________________ Have You Ever been Diagnosed with:
Abdomen or Pelvis
Please describe: ______________________________________________________ Are You having Abdominal or Pelvic Pain ? No Yes
Please describe: ________________________________ Do you have any family history of Bowel Disease?
Who?_____________________________________ What condition?_____________________________ Do you have any known colon problems: No Yes
Please describe:_________________________________
Print Name__________________________________ DATE_____________

Past Colon-related medical procedures? No Yes
Colonoscopy __when ___Polyp biopsy/removal __when___ Barium Enema _____when ______other ____when_____ Do you have a history of Hemorrhoids? No Yes
Do you have Rectal Bleeding? No Yes
Has there been a recent change in your bowel habits or stools? No Yes Recent Unintentional Weight Loss: No Yes
Have you seen a physician for the above conditions? Physician's Name ______________________________
Medications currently taking: ___________________________________________ ___________________________________________________________________ Smoking History
If you smoke: Packs/ day ____________ Years smoking ____________
Print Name_____________________________ DATE__________________

Virtual Colonoscopy Disclosure and Consent

I voluntarily consent and authorize Front Range Preventive Imaging physicians and technologists to
administer the testing required to perform a CT Virtual Colonography Scan.
Furthermore, I understand that:
1. The primary purpose of the colon screening is to detect early cancer or other abnormalities when the
2. Although this is an excellent tool, it is not perfect and can miss some abnormalities including cancers at the very early stages of development and should not be considered as a substitute for a complete evaluation by a physician. 3. If an abnormality is found a recommendation for an optical colonoscopy will be made. ______ Initial
4. I will be exposed to approximately 5 mSv of radiation during the procedure.
5. Since CT is very sensitive, it may identify nodules and/or other abnormalities that are insignificant or
not cancerous, but may require additional diagnostic tests and/or procedures to evaluate the findings. 6. Such tests and/or procedures may entail additional costs for which I am responsible. 7. Radiology is not a perfect science and it is possible for a radiologist to miss a significant lesion or 8. Front Range Preventive Imaging is not responsible for my follow-up medical care.
9. My test results will be made available to the physician of my choice.
10. If I develop pain, fever, chills or any other unusual symptom or symptoms related to the colon,
abdomen or pelvis, I should seek medical attention and advice. 11. The colon will be inflated with CO2 in order to help visualize the colon.
I have been given an opportunity to ask questions about this procedure and the risks and hazards involved
and I believe that I have sufficient information to give informed consent. I certify that I have read this
form and I understand its contents.
The report for this procedure contains medical terminology that is likely to require interpretation by a
physician.
In order to allow patients to take this test, Front Range Preventive Imaging requires that you:
1. Identify the name of a physician below to whom we can send a copy of your medical 2. If you are a female, is there any chance you may be pregnant? NO (please circle one) Technologist Initials_______________
Would you like a copy to go to a medical provider I hereby consent that Front Range Preventive Imaging may send a copy of the medical report for
this procedure to my physician:

_____________________________________________________________________________________
Physician Name
_____________________________________________________________________________________
Physician Address
_(______)__________________________
Physician Phone Number
Patient Signature: _________________________________________ Date:____________________

Policy Regarding Messages
In an effort to protect your privacy, we have developed a policy on leaving medical care messages.
We will NOT leave messages with anyone except the patient or legal guardian.
We will NOT leave any information on an answering machine/voice mail.
UNLESS
we have your written permission to do so.
Please read below and consider carefully whom you want to have access to your medical information. I, ____________________________, give Front Range Preventive Imaging my permission to leave phone messages regarding my medical care and information as listed below. I fully understand that this authorization will remain valid until revoked in writing. My home/mobile answering machine/voice mail: My spouse: Name __________________________ Other: Name ______________________________
Financial Policy

We are committed to providing you with the best possible care, and are pleased to discuss our professional fees with you at any time. Your clear understanding of our Financial Policy is important to our professional relationship. We must emphasize that as health care providers, our relationship is with you, not your insurance company. Any benefits quoted to you are NOT a guarantee of payment from the insurance company. • Your insurance is a contract between you, your employer, and the insurance company. • Patients covered under a PPO / HMO plans are responsible for complying with the PPO / HMO rules, regarding written and phone referrals from primary care physicians, if that is a requirement of your plan. • Failure to comply with the referral requirements of your plan will make it necessary for us to bill you directly for charges incurred during a non-referred visits. • We will process claims with PPO /HMO plans with which we have a contract agreement, according to that • Required co-payments, if applicable, should be made on the day services are provided. You are responsible for all co pays, deductibles, coinsurance, and amounts not covered by your Ins. Co. You will be billed for any balance on your account after the Ins. has paid their portion.
Payment for service is due at the time service is rendered. You are responsible for timely payment of your
account, and for any balance remaining after insurance payment has been received. There will be a $25.00 charge for all checks returned for insufficient funds. I have read the above information; I understand and agree that I am responsible for payment of services rendered. Notice of Health Information Practices
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
Introduction
At Boulder Internal Medicine and Front Range Preventive Imaging, we are committed to treating and using
protected health information about you responsibly. This Notice of Health Information Practices describes the
personal information we collect, and how and when we use or disclose that information. It also describes your
rights as they relate to your protected health information. This Notice applies to all protected health information as
defined by federal regulations.
Your Health Information Rights
Although your health record is the physical property of Boulder Internal Medicine and Front Range Preventive
Imaging, the information belongs to you. You have the right to:
• Obtain a paper copy of this notice of information practices upon request, • Inspect and copy your health record (a reasonable fee will be required),
• Request an amendment of the health record, • Obtain a list of the disclosures of the health information, • Request restrictions on certain uses and disclosures of your information, and • Revoke your authorization to use or disclose health information except to the extent that Our Responsibilities
Boulder Internal Medicine and Front Range Preventive Imaging is required to:
• Maintain the privacy of the health information, • Provide you with this notice as to our legal duties and privacy practices with respect to • Abide by the terms of this notice, and • Notify you if we are unable to agree to a requested restriction. We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will provide the updated policy at the time of a future visit or you may obtain a copy of the revised notice by stopping by our facility. We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue to use or to disclose your health information after we have received a written revocation of the authorization. We will provide health information without authorization when necessary to provide you with treatment, to
receive payment or prior authorizations from third parties, and for healthcare operations.

Business associates: There are some services provided by or for Boulder Internal Medicine and Front Range
Preventive Imaging through contacts with business associates. Examples may include physician services in the emergency department and radiology, certain laboratory tests, and a transcription service. When these services are used, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. We require our business associates to appropriately safeguard your information. Communication with family: As health professionals, using our best judgment, we may disclose to a family member, other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care. Contacts: We may contact you to provide appointment or follow-up reminders, information about treatment alternatives, or other health related benefits and services that may be of interest to you. Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement. Workers compensation: We may disclose health information about you for worker’s compensation or similar programs, which provide benefits for work related injuries or illness. Public health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Correctional institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals. Law enforcement: We may disclose health information for law enforcement purposes as required by law in specific circumstances, for military or national security purposes, in response to valid judicial or administrative orders, or to avoid a serious heath threat.
Federal law makes provision for your health information to be released to an appropriate health oversight agency,
public health authority or attorney, provided that a work force member or business associate believes in good faith
that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards and are
potentially endangering one or more patients, or the public.
I have received and read this Notice of Health Information Practices. I fully understand this Notice
and have had all my questions answered.
__________________________________ _____________________________________________
Print Name Signature Date
For More Information or to Report a Problem
If you want additional information or if you believe your privacy rights have been violated, you can file a complaint
with Boulder Internal Medicine and Front Range Preventive Imaging or contact the Office for Civil Rights, U.S.
Department of Health and Human Services. There will be no retaliation for filing a complaint. The address for the
Office for Civil Rights is listed below:
U.S. Department of Health and Human Services

Source: http://www.frontrangepreventiveimaging.com/wp-content/uploads/2013/08/Colon-Paperwork.pdf

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