Patient Information

Last Name:

First Name:

Middle Name:

Sex:

M F

Social Security Number:

Marital Status

Married Single Divorced Widowed

Date of Birth:

Race

African-American American-Indian Asian Caucasian Hispanic Pacific Islander Other

If Other, please indicate here:

Ethnic Group/Nationality:

Primary Language:

English Portuguese Español Other

If Other, please indicate here:

Home Address:

Apt:

City:

State:

Zip:

Home Phone:

Work Phone:

Cell Phone:

Primary Doctor & telephone number:

Preferred Pharmacy Name, Location, and Number:

Cardiologist Name & phone number:

Who referred you to our practice?

What is your email address:

Insurance Information

Primary Insurance Company:

Secondary Insurance Company:

Under whose name is your insurance?

Self Others

If Other, Please indicate names:

What is their date of birth?

What is your relationship?

What is their Social Security Number?

Patient Confidentiality

Patient confidentiality is of great concern to our office. Please indicate below with whom our office may speak or leave a message with regarding your health, medication, test results, etc.

Name:

Relationship:

Phone Number:

Add another individual

May we call you at work?

Yes No

May we leave a voicemail?

Yes No

Patient Agreement

Should inaccurate or omitted insurance information be supplied causing a reduction or non-payment of benefits, the obligation of payment will be transferred to the responsible party. I hereby authorize the release of any medical information for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Advanced Gastroenterology Group. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original.

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

Patient Signature:

Date:

Your information will be encrypted.