Patient Candidacy Screening · Digestive Center
Digestive Center · A Center for Autoimmune Gastroparesis
Patient Candidacy Screening

Find out if our Gastroparesis Care Program may be right for you.

Answer five short questions to help us understand your situation. This takes about two minutes, and a care coordinator reviews every response in collaboration with your primary physician.

Takes about 2 minutes
Reviewed by a coordinator
No obligation

Thank you, your screening has been received.

A care coordinator will review your responses and reach out within one business day. If your situation is urgent, please contact your physician.

Based on your responses, you may be a candidate.

Your personalized form is ready

It already includes your screening answers. Save or print it and bring it to your physician.

Download My Form

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What happens next

1
Download your form using the button above, then save or print a copy for your appointment.
2
Give it to your physician. Your doctor reviews the form, orders the recommended blood work, and records your results directly on it.
3
Your physician sends it back to us. Ask your doctor's office to return the completed form, with your results, so our team can review it and reach out about next steps. They can send it by:

For privacy, please ask the office to return the form through a secure, encrypted channel (fax or encrypted email) rather than standard email.

We've also emailed you a copy of your form and these instructions, so you always have it on hand for your appointment.

Patient Candidacy Screening

Please answer all questions below to help us determine if you may be a candidate for our program, in collaboration with your primary physician.

1 Are you currently under the care of a gastroenterologist or digestive health specialist?
2 Have you been diagnosed with any of the following?

Select all that apply.

3 Do you experience any of the following conditions or symptoms?

Select all that apply.

4 Do you regularly experience symptoms such as nausea, vomiting, bloating, or feeling full very quickly that impact your daily life?
5 Have you had a gastric emptying study (GES) performed?

Where should we send your results?

A coordinator will use this to follow up about your screening. We never share your information.

Your information is kept private and used only to coordinate your care.

This screening form is for informational purposes only and does not constitute medical advice or a diagnosis. Results are a preliminary indication only. A qualified healthcare provider will make all final determinations regarding your care.

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Advanced, coordinated care for complex, autoimmune gastroparesis.

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Candidacy Screening Refer a Patient Insurance & Coverage
The Digestive Center provides this website for general educational purposes. It is not medical advice and does not replace consultation with a qualified physician. This screening tool produces a preliminary indication only and is not a diagnosis. Infusion-based therapies, including intravenous immunoglobulin (IVIG), may not be appropriate for every patient; candidacy and treatment are determined through individual clinical evaluation. Insurance coverage varies by carrier and individual plan, and verification of benefits does not guarantee payment.
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