Charlotte Gastroenterology & Hepatology | Forms - Charlotte Gastroenterology & Hepatology

Appointments: 704.377.0246 General: 704.377.4009

Referring MDs MyChart Online Payment Center

Patient Forms

We know your time is important. Therefore, we have provided our most commonly used forms online to help expedite the check-in portion of your visit to our office.

Procedure forms

For the fastest service, please complete the online form. If you are unable to complete the online form, please complete the printable form. To return the printable form, you may fax it to 704-602-6578 or return to the closest CGH location.

complete the form online

Notice of Privacy Rights & Friends and Family FOrms

Notice of Privacy Practices- Lake Norman Endoscopy Center

Notice of Privacy Practices- CGH

Friends and Family Form- Lake Norman Endoscopy Center

Friends and Family Form- CGH

Colonoscopy Preparation Instructions

Medical Records Release Form

Authorization and Fee Guide for Release of Records Authorization to Release Medical Information to CGH

Forms

Procedure forms

complete the form online

Notice of Privacy Rights & Friends and Family FOrms

Recall Medical History Form

Recall Patient Registration Form

Patient Satisfaction Survey (Endoscopy Division)

Patient Satisfaction Survey (Medical Group)

Patient Rights

Open Access Colonoscopy Medical History Form

Open Access Patient Registration Form

Colonoscopy Consent Form

Conscious Sedation Consent Form

Upper Endoscopy

Colonoscopy Preparation Assistance

Financial Hardship and Financial Assistance Policy

Acknowledgement of Receipt of Patients’ Rights and Advanced Directives

Colonoscopy Preparation Instructions

Medical Records Release Form

GI Links

Additional Links

MyChart at Charlotte Gastro

MyChart Access

Forms

Procedure forms

complete the form online

Notice of Privacy Rights & Friends and Family FOrms

Recall Medical History Form

Recall Patient Registration Form

Patient Satisfaction Survey (Endoscopy Division)

Patient Satisfaction Survey (Medical Group)

Patient Rights

Open Access Colonoscopy Medical History Form

Open Access Patient Registration Form

Colonoscopy Consent Form

Conscious Sedation Consent Form

Upper Endoscopy

Colonoscopy Preparation Assistance

Financial Hardship and Financial Assistance Policy

Acknowledgement of Receipt of Patients’ Rights and Advanced Directives

Colonoscopy Preparation Instructions

Medical Records Release Form

GI Links

Additional Links

MyChart at Charlotte Gastro

MyChart Access

Important Patient Notice

February 3rd & 4th