Two minutes of questions.
One week to an answer.

A physician reviews every submission. If the assessment isn’t right for you, we’ll tell you before you pay a dollar.

Company

Full name Email Mobile phone State of residence

What brings you here

Unexplained iron deficiency or falling ferritin

Chronic fatigue without a clear cause

Bloating / abdominal pain / “IBS” after normal scopes

GI bleeding with no source found

Something else

Safety screening — required

Have you ever had any of the following? Check all that apply. (These don’t necessarily disqualify you — they tell the physician what to review.)

Crohn’s disease or suspected bowel strictures

Bowel obstruction or abdominal/bowel surgery

Daily NSAID use (ibuprofen, naproxen) for 6+ months

Difficulty swallowing pills

Prior abdominal radiation therapy

Pacemaker, defibrillator, or other implanted device

Currently pregnant

None of the above

Add the Absorption Panel (+$199) — celiac serologies (tTG-IgA, total IgA) + micronutrient absorption markers (B12, folate, zinc, vitamin D), drawn at the same lab visit. One blood draw · Reviewed in the same physician visit

Anything else the physician should know? (optional)

I understand this questionnaire does not create a physician–patient relationship, that a physician will review my responses to determine whether the assessment and any capsule study are appropriate, and I consent to be contacted by Premier Regenerative Health by phone, text, or email about my request.

Next: pick your telehealth time & pay securely

Important information. The Traverse Scan™ program uses the CapsoCam Plus® capsule endoscope (CapsoVision, Inc.), FDA-cleared for visualization of the small bowel. It is not a replacement for colonoscopy or upper endoscopy and does not screen for colorectal cancer. A physician determines medical appropriateness for all services; not all applicants will be candidates. If you are experiencing severe abdominal pain, black or bloody stools, vomiting blood, or other urgent symptoms, do not use this form — seek emergency care immediately.

Two minutes of questions.One week to an answer.

Two minutes of questions.
One week to an answer.