Charlotte Gastroenterology & Hepatology | Forms - Charlotte Gastroenterology & Hepatology

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.

Please print out and complete the PDFs below. Please bring to your appointment, or mail to our office.

We are currently in the process of working on a new online forms platform.

Open Access Colonoscopy Forms

Recall Patient Forms

Recall Patient Registration Form

› Recall Patient Registration

Recall Medical History Form

› Recall Medical History

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

Recall Medical History Form

View or print PDF

Fill out form online

Recall Patient Registration Form

View or Print PDF

Fill out form online

Patient Satisfaction Survey (Endoscopy Division)

Fill out form online

Patient Satisfaction Survey (Medical Group)

Fill out form online

Patient Rights

View or print PDF

Notice of Good Faith Estimate

Open Access Colonoscopy Medical History Form

Fill out form online

Download PDF

Open Access Patient Registration Form

View or Print PDF

Fill out form online

Colonoscopy Consent Form

English
Espanol
Vietnamese

Conscious Sedation Consent Form

English
Espanol
Vietnamese

Upper Endoscopy

Upper Endoscopy (EGD) Prep English or Spanish
Preparacion Para Endoscopia Superior
English- Consent Form
Espanol- Consent Form
Vietnamese- Consent Form

Colonoscopy Preparation Assistance

Frequently Asked Questions

Clear Liquid Diet- English or Spanish Colonoscopy Sample Diet- English or Spanish

Indigent Care Policy and Procedure

Acknowledgement of Receipt of Patients’ Rights and Advanced Directives

View or print PDF (CGH)
View or print PDF (Endoscopy Center of Lake Norman)

Colonoscopy Preparation Instructions

Medical Records Release Form

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

Forms

Open Access Colonoscopy Forms

Open Access Patient Registration Form

Open Access Colonoscopy Program Medical Questionnaire

Open Access Colonoscopy Program Medical History Form

Recall Patient Forms

Recall Patient Registration Form

Recall Medical History Form

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

Indigent Care Policy and Procedure

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