Schedule Your Colonoscopy
Name:
Telephone:
(enter number to best contact you)
E-mail: (optional)
I would like to receive information via email from ThedaCare in the future*
* We will not sell your information and/or send you spam messaging
Date of birth: (optional)
Best approximate time to contact you:
(e.g. - Monday, Sept. 28 after 9am)
Primary Care Provider:
Do you have a preference of physician to perform the procedure (you have seen a physician before or have received a recommendation from family member or friend)?
Yes
No
If yes, please list:
Do you have a preference of location for the procedure?
Theda Clark, Neenah, WI
Appleton Medical Center, Appleton, WI
No preference
