Colonoscopy Request Form

Time for your colonoscopy? Request an appointment time by filling out the email form below! A Bon Secours representative will respond to your request at the phone number or email you provide within the next 2-4 business days to confirm your appointment.

This form is for a routine screening colonoscopy. In order to self-schedule a colonoscopy, the patient must meet the following criteria:

  • Between the ages of 50 – 65 if no family history of colon cancer OR any age if immediate family member has history of colon cancer before the age of 50
  • No previous history of gastrointestinal conditions
  • No significant medical problems

If you meet these criteria please fill out the form below.