Consumer Access Request Form

Consumer Access Request - Baylor Scott & White – Endoscopy Center at Sherman

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Name*

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Telephone Number*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

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Information Being Requested

Specific pieces of personal information, collected or shared with third parties and for what business/commercial purpose.

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Direct Screen Colonoscopy Form

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By checking the box below, you certify that you understand that our facility’s website is not secured as we do not collect personal or private health information via our site. Accordingly, the “Contact Us” form is not intended for use with personal or private health information, however, e-mail sent via the “Contact Us” form is sent to a facility employee on a secure e-mail server. This form is for new patients inquiring about our facility and services. If you are a current patient, please call us at 903.437.6260.

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Consumer Access Request Form

Consumer Access Request - Baylor Scott & White – Endoscopy Center at Sherman

Information Being Requested

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Direct Screen Colonoscopy Form