New Patient Packet

Last name

First Name

Middle Name

Please upload PDF files of your Insurance Card(s) (Front & Back)

Add file

Please upload a file

Please upload a PDF file your Driver's License (Front)

Add file

Please upload a file

Please upload your Covid-19 Immunization Card (Front & Back)

Add file

Please upload a file

Date of Birth

Current Height

Current Weight

SSN #

Email address

Address

City

State

Zip

Primary or referring Dr.

Employer

Home Phone

Cell Phone

Work Phone

Consent for the Use of Text Messages and Phone Calls for Health Related Purposes

We may use automated or purposefully initiated phone calls and text messages to provide you with updates regarding your appointments, health results, and the management of your medical condition.

"I give my permission to Gilroy Gastro to contact me via text messages or phone calls with regards to the management of my health. I am aware that carrier charges may apply."

Communicating with the patient is an integral part of patient care, and the above consent is an implied part of your agreement to seek healthcare with us. If you do not agree, then please inform us as we may not be able to take care of you.

Pharmacy Name and Location

Language

Race

Ethnicity

Insurance

ID #

Group #

Emergency Contact

Relationship

Home Phone

Cell Phone

Prince Shah, M.D & Kevin D. Stuart, M.D are separate solo practices that share a medical record system and provide coverage for each other's patients. If you obtain continued medical care at this facility, it is taken as implied consent to the above arrangement.

A holder of this medical debt contract is prohibited by Section 1785.27 of the Civil Code from furnishing
any information related to this debt to a consumer credit reporting agency. In addition to any other penalties allowed by law, if a person knowingly violates that section by furnishing information regarding this debt to a consumer credit reporting agency, the debt shall be void and unenforceable. This applies only to new patients who have never received care from us. If you have a pre-existing relationship, then this does NOT apply to you.

AUTHORIZATION TO PAY BENEFITS TO PHYSICIAN: I hereby authorize payment directly to you, for all medical and or surgical benefits, if any, otherwise payable to me for services rendered. I understand that I am responsible for all charges whether or not paid by insurance.

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize the doctor to release any information acquired in the course of my examination and treatment necessary to secure the payment of the insurance benefits. I also, AUTHORIZE RELEASE OF ANY MEDICAL INFORMATION, TO referred Physician's office as necessary, for my care and treatment.

Please Check to confirm you have read the HIPPA compliance

Please Check to confirm you have read the Financial Interest for GEC

Please Check to confirm you have read the Pharmacy consent form

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.

Signature

Date

Medical History Questionnaire

Instructions: You may leave this section unanswered if you prefer. You will receive a call from our AI intake agent approximately 24 hours before your appointment to review this information.

General State of Health?

Excellent Good Poor Fair

Are you allergic to Any Medications

Yes No

Please List

Do you have any other Allergies?

Yes No

Please List Allergies

Do you have sleep apnea?

Yes No

Have you had Surgery in the past?

Yes No

Please List

Prescriptions

Over the counter (Aspirin, Motrin, Etc.)

DOES ANYONE IN YOUR FAMILY HAVE:

Relationship

Type

List Date

Do you drink alcohol?

Non-Drinker Socially

(1-2 Times a week)

Regular

(Almost Everyday)

Excessive

If you selected Excessive, please explain here

Do you smoke tobacco

Current Past Never Smoked Other

If you selected Other, please explain here

Do you vape

No Yes

If yes, please detail what product and how frequently

Marijuana use

No Yes

If yes please detail type/amount and frequency

Any other substance abuse

No Yes

If yes please detail which one, and when last used

Signature

Date

Review of Systems

Instructions: Please check the ☐ if you are currently experiencing any of the following symptoms. If no, leave it unchecked.

General / Constitutional

Fever

Night sweats

Fatigue or unusual tiredness

Unintentional weight loss

Eyes

Trouble with vision

Eye pain

Sensitivity to light

Ears, Nose, Throat (ENT)

Hearing problems

Ear, nose, or throat pain

Runny nose /Nasal congestion

Nosebleeds

Hoarseness or voice changes

Dental problems

Cardiovascular

Chest pain

Palpitations

(awareness of heartbeat)

Rapid heartbeat

(tachycardia)

Shortness of breath when lying flat

(orthopnea)

Swelling of legs, ankles, or feet

(edema)

Respiratory

Cough

Shortness of breath

Coughing up blood

Genitourinary

Blood in urine

Frequent urination

Urinary incontinence

Genital sores or lesions

For women only

Heavy or frequent menstrual bleeding

Abnormal pain during menstruation

Vaginal discharge

Musculoskeletal

Joint pain

Back pain

Muscle aches

Skin / Breast

New or changing moles

Itching

Rash

Nipple discharge

Breast lumps or masses

Neurological

Dizziness

Headaches

Numbness or tingling

Isolated weakness in any part of the body

Hematologic

Easy bruising

Easy bleeding

Swollen lymph nodes

Endocrine

Hair loss

Heat intolerance

Cold intolerance

Excessive thirst

Excessive hunger

Immune System

Environmental Allergies

Hives

Psychiatric

Anxiety

Depression

Sleep disturbances

In your own words please describe your problem and the issues you want us to address during your visit

Please upload any additional labs, radiology reports or medical records you feel are relevant to your visit:

Add file

Please upload a file

Patient Contact List

Authorization to speak with spouse, relative, or person of your choice. Allows persons listed to speak with staff/physician regarding your health information. Please list contacts below if interested.

Check here if you DECLINE patient contact list

Last Name

First Name

Middle Name

Phone #

Relationship

Last Name

First Name

Middle Name

Phone #

Relationship

Signature

Date

After you submit this form, a virtual intake assistant may call to collect additional information to help your doctor prepare for your visit. The assistant speaks English only. You may have someone assist you during the call, if needed. The information collected is private and for your medical care only and there is no additional charge for it. If this is acceptable to you, please select a convenient date and time for the phone call.

I agree to receive a phone call from the virtual intake assistant and will select a preferred date and time below. I decline a phone call from the virtual intake assistant.

*Dr. Shah requests you to reconsider and urges you to agree to accept a call from the virtual assistant. This will help enhance the quality of the care we can provide to you.*

Date

Hour

Minutes

AM/PM

AM PM

Your information will be encrypted.