Patient Forms

The following list of forms are available for you to print out to complete and bring with you to your procedure or appointment.  They are listed by the possible locations where we may have scheduled your procedure.  Any forms that are required for a particular location will be indicated as such.

DHA Endoscopy Center at Montvale Avenue

• Pre-Admission Questionnaire (Required)
• Medication Reconciliation Sheet
• Patient Rights Statement

Winchester Hospital GI Suite and Endoscopy Center at Commerce Way

• Medication Reconciliation Sheet (Required)

Instructions/Preps

The following list of instructions and procedure preparations are available to help you prepare for your upcoming procedure with DHA.  Please follow instructions only for the specific prep that has been prescribed by your physician.

Colonoscopy Preparations

(Select one of the following, as instructed by your physicians' office)

• Citrate of Magnesium
• SUPREP
• CLENPIQ
• TriLyte, Nulytely or Golytely (Standard Dose) Prep
• TryLyte, Nulytely or Golytely (Split-Dose) Prep
• TryLyte, Nulytely or Golytely (Low Volume) Prep
• Miralax G2 Split Prep

• Low Roughage Dietary Recommendations
• Low-Fodmap Diet

Upper GI Endoscopy/ Gastroscopy Preparation

• Gastroscopy (Upper GI Endoscopy) Prep

Sigmoidoscopy Preparation

• Sigmoidoscopy Prep
• FAQ's
• Helpful Links
• Patient Portal

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