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 download and print the attached form and complete and sign where indicated. Please bring these pages to your procedure.

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

Demographic Sheet

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

Please download and print the attached form and complete the Medical Authorizations and Release Information form, as well as print the Conscious Sedation page. Bring both of these pages to your procedure.

Download Form

Patient Procedure Form

Please print, review, sign and bring with you to your procedure along with an Advanced Directive if possible.

Please download and print the attached form and review your rights and responsibilities as apatient, our policies regarding advance directives,and your physician’s financial interest in ourfacility. 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