Patient Forms
At the Fort Wayne Endoscopy Center, no physician referral is required. A confidential pre-screening, however, is necessary before the cancer screening procedure can be scheduled. The medical, insurance and medication questions that need to be answered can be collected one of two ways, either e-mail or telephone interview.
To access the pre-screening questionnaire and respond by email, simply click the pre-screening assessment link below.
To schedule a telephone interview call the Cancer Screening Message Center at 260-266-9085 or Toll Free at 877-870-0301 (anytime, 24 hours) and listen to a brief message. Then leave a name and phone number. A knowledgable specialist will return the call and conduct the pre-screening interview by phone.
In both cases the answers are reviewed by one of the staff physicians prior to performing the procedure. All responses will be held in strict confidence. Once scheduled, the procedure is done at the Center, 3415 Hobson Road, in Fort Wayne.
All fields marked with a red asterisk are required. If you prefer, you may also click here to download a PDF version of the form and fax it to: 260-266-9088
Patient Pre-Screening Form
Doctor Referrals
Please complete the following form and press submit at the bottom of the page. If you prefer, you may also click here to download a PDF version of the form and fax it to: 260-266-9088