New Patient Forms

Peninsula Gastrointestinal Specialists, Inc

Please correct the errors described below.

Patient History

Add another medical problem/ hospitalization/ surgery

Add another medication

Social History




Add new row for another brother/sister

Add new row for another child

Add new row for another family member

Review of Systems (select all that apply)











(Office use: 10+ complete)

Acknowledgement of Receipt of Notice of Privacy Practices

To Our Patients:

In accordance with Federal Law on the Patient Privacy, please read the following:

This statement is to advise you that our office has a Privacy Policy (complete policy in waiting room) in place to protect your medical information. In brief, our policy states that our office will keep your
medical record information confidential and will use it only for treatment, payment and healthcare operations. The office may release information to other doctors during emergencies, or cases of
neglect and abuse. Our policy identifies your rights to access your records, request restrictions on who can see and be informed of your medical information. In short, to keep your communications
with this office confidential.

Our Privacy Policy can be reviewed in its entirety, or you may request a copy.

You have my permission to release my medical information to the following: (please check and list name and phone number)

Patient Information

(optional, unless needed for insurance billing purposes please complete)
(we would like photocopy of all your insurance cards)

I hereby authorize my insurance benefits to be paid directly to the physician and I understand that I am financially responsible for all non-covered charges. Payment is due and payable at the time services are rendered. I understand that my credit card is on file and that any remaining balance I owe may be charged to my credit card. I also authorize my physician to release any information to my insurance company for the processing of my insurance claims. HMO patients who do not have prior authorization to see Dr. Onuma or Dr. Lee will be financially responsible for any charges incurred.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.