call Internal Medicine Associates at 907-276-2811 to schedule an appointment

LOCATION
2841 DeBarr Rd, Ste 51
Anchorage, AK 99508

CONTACT
(907) 222-3636
reception@aecak.com

Patient Forms

Thank you for scheduling your upcoming procedure at Anchorage Endoscopy Center. As an ambulatory outpatient facility, we are required to provide you with certain information prior to your procedure.

Advanced Directive

Please print, review, sign and bring with you to your procedure.

You have the right to give instructions about your own health care to the extent allowed by law.

Download Form

Informed Procedure Consent

Please print, review, sign, and bring with you to your procedure.

Please review the procedure consent form prior to your procedure. Your physician will discuss this with you during the admitting process, and you will then sign, giving permission to perform the procedure(s). Please feel free to ask any questions or discuss any concerns with him/her at this time.

Download Form

Anesthesia Consent

You have the right to be informed about your condition and the recommended surgical or medical
procedure requiring anesthesia. This information will assist you in making the decision whether to
undergo the procedure after knowing the risks and hazards of anesthesia involved.
Download Form

Patient Procedure Form

Please bring your completed demographic sheet and health history form.

Your rights and responsibilities, our policies regarding advance directives, and your physician’s financial interest in our facility are included in these documents. Also, our financial policy and billing acknowledgment are included for your review.

Please download and print the attached form and review your rights and responsibilities as a patient, our policies regarding advance directives, and your physician’s financial interest in our facility. Our patient financial policy and billing acknowledgment are also included for your review. The Health and History Questionnaire needs to be filled out completely and brought with you to the procedure.

Download Form