21 Jefferson Place, Athens, GA 30601

(706) 548-0058 706-548-0555

Athens Gastroenterology Center

Home
About Us
Athens Endo
Services
Hemorrhoid Bands
Referrals
Reviews
Contact Us

Hemorrhoid Banding Forms

Hemorrhoid Banding Candidacy Questionnaire

Please complete this form before your consultation. Your responses will help determine if hemorrhoid banding is the best treatment option for you.

Patient Request for GI Appointment

Free Text

Patient Information

Full Name:

Date of Birth

Phone Number:

Email Address:

Primary Care Physician:

Referring Physician (if applicable):

Free Text

Eligibility Assessment

1. Have you been diagnosed with internal hemorrhoids by a healthcare provider?

Yes

No

2. Which of the following symptoms do you experience? (Check all that apply)

Bright red bleeding during or after bowel movements

Rectal discomfort or pain

A sensation of incomplete bowel movement

Protruding hemorrhoids that retract on their own

3. Have you previously tried conservative treatments such as fiber supplements, sitz baths, or topical creams without relief?

Yes

No

4. Have you been diagnosed with any of the following conditions? (Some conditions may affect candidacy for hemorrhoid banding.)

Blood clotting disorders (e.g., hemophilia, thrombocytopenia)

Severe inflammatory bowel disease (Crohn’s disease, ulcerative colitis)

Rectal or anal cancer

Active anal infections (abscesses, fistulas)

HIV/AIDS or other immune-compromising conditions

Cirrhosis or severe liver disease

None of the above

5. Are you currently taking any blood-thinning medications (e.g., aspirin, Plavix, Xarelto, Coumadin, Eliquis)?

Yes

No

If yes, please list:

6. Do you have a history of complications with medical procedures, sedation, or anesthesia?

Yes

No

If yes, please describe:

7. Have you previously undergone hemorrhoid banding or surgical treatment for hemorrhoids?

Yes

No

If yes, when?

8. Do you currently have any signs of infection (fever, pus, severe pain) in the rectal area?

Yes

No

9. Are you pregnant or planning to become pregnant soon? (Pregnancy may affect treatment options.)

Yes

No

10. Do you have any concerns about undergoing hemorrhoid banding?

Yes

No

If yes, please specify:

Free Text

Candidacy Confirmation

Opt-In

I understand that my responses will be reviewed by a medical provider to determine if hemorrhoid banding is an appropriate treatment for me

Opt-In

I acknowledge that additional evaluation may be required before proceeding with the procedure.

Free Text

Quick & Effective, Minimal discomfort or complications/risks. No prep required, No sedation required & no designated driver needed. Return to work and most normal activities the same day of procedure.

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

We will call the patient to give them their appointment information.

THANK YOU AGAIN FOR YOUR REFERRAL!

Athens Gastroenterology Center

Our center of excellence also provides a Quad A certified Ambulatory Surgical Center for endoscopy.

Quick Links

Home
About Us
Services
Contact Us

Contact Us

Address: 21 Jefferson Pl, Athens, GA 30601, USA

Phone: (706) 548-0058

© 2025 All Rights Reserved | Legal Notices | Designed and Developed by Solution21, DBA Web Concepts Media.

Share by: