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Patient Forms

At Connecticut Colon & Rectal Surgery, LLC, we understand that your time is valuable and strive to make your visit as efficient as possible. To ensure this, please download and complete the patient forms prior to your appointment.  Please bring the completed forms with you to your appointment, along with your valid insurance card and photo ID. This will help to expedite the check-in process. If you are unable to download and complete the forms prior to your appointment, please arrive 15 minutes early to your appointment to fill out the necessary paperwork.  If you have any questions, please contact us. We look forward to seeing you soon.

New Patient Forms

If you are a new patient to Connecticut Colon & Rectal Surgery, please be sure to fill out the required new patient forms prior to your appointment. These forms are imperative to a smooth and efficient visit, allowing us to give you the best care possible. If you have any questions or concerns, please don't hesitate to contact us.

Annual Forms

At Connecticut Colon & Rectal Surgery, we understand the importance of staying updated with our patients' medical information. As such, we require our annual patients who were seen within the last one to three years to complete our patient forms before their appointment. These forms will ensure that our team has the most up-to-date information regarding your health. Please download the forms, complete them, and bring them with you to your appointment. We look forward to seeing you soon!

Simplify Your Patient Forms Process

Our patient forms are here to save your time during your first appointment with us. Our team has carefully crafted these forms to gather all of the necessary information to provide you with the best care possible. Please feel free to print out the forms that you need and complete them prior to your visit. If you forget to print out a page, don't worry! Just print out the form you need and complete it prior to your appointment.


At our office, we take the privacy of our patients very seriously. We are committed to protecting your protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA). To ensure compliance, we ask that all patients complete a HIPAA Authorization form prior to their appointment. Please bring the completed form with you to your visit. This form will allow us to share your information with other healthcare professionals as necessary. Thank you for helping us to maintain HIPAA compliance.

E-mail and Text Message Consent Form

The E-mail and Text message Consent Form outlines the agreement between the patient and doctor to use electronic communication methods for communication. By signing the form, the patient provides consent to receive communication such as appointment confirmations, reminders, and other important information via email and text message. The form also includes a space for the patient to indicate their preference for receiving communication.  We take your privacy and security seriously; therefore, all data we collect will remain confidential.

Patient Financial Responsibility Agreement

We require all patients to sign a Patient Financial Responsibility Agreement prior to receiving treatment. This agreement outlines the patient's financial responsibility for their treatment, including any co-pays, deductibles, fees, and other costs associated with the care they are receiving. This keeps our billing and collection process transparent and allows us to provide the best care possible. We want to ensure that our patients understand their financial obligations before they come in for their appointment. If you have any questions about the agreement, please contact our office for more information.

Patient Treatment Agreement

Patients are responsible for keeping their appointments or notifying the doctor in advance if they need to reschedule. 

Medication - Allergy list

It is important for patients to provide their doctor with an accurate list of any medications, supplements, and vitamins they are currently taking. This information should also include any allergies and reactions they may have to any medications, food, or other substances.  It is important to be as detailed as possible in order to ensure that any potential interactions are identified and that the safest and most effective treatment plan can be developed.  Allergies and reactions must be reported to the doctor immediately as they may change the course of the treatment plan. It is also important to keep this information up to date as medications, vitamins, and supplements can change over time.

Pharmacy - Physician List

We understand that managing your healthcare is important to you. Please provide a complete list of all doctors that you see on a regular and yearly basis, as well as the pharmacy that you use. This information helps us ensure our patients are receiving the best care possible. We also ask that our patients keep us updated if any changes occur to their doctor or pharmacy list. Our team is always here to answer any questions and provide assistance.

Open Access Colonoscopy

Scheduling of an Open Access Colonoscopy with Connecticut Colon & Rectal Surgery, LLC is easy.  No prior office visit is required, for those that meet the criteria. If you’re in good health and wish to proceed with scheduling your colonoscopy procedure, we ask that you fill out the open access colonoscopy questionnaire completely and accurately as well as providing a copy of all your insurance cards (front and back). Once this form is filled out it can be submitted to our office via postal mail or by fax. Once the office receives the forms, one of our physicians will review your records.  Please allow three business days for your information to be reviewed by one of our physicians.  If you qualify for an open access colonoscopy, our office staff will contact you to schedule your procedure.  If you do not qualify, our office staff will contact you to schedule an office visit your needs with one of our highly-skilled providers.  We will also help you deal with and answer all questions regarding the open access colonoscopy.

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