Procedure Form

Patient's Name

Date

Procedure

Date of Birth

Arrival Time

Diagnosis

PLACE

Digestive Health Center of Plano (Preston Crossing Endoscopy Center) 3500 Preston RD STE# 200 Plano, TX 75093 (972) 985-2300

Medical City Plano Hospital 3901 W. 15th St. Plano, TX 75075 (972) 596-6800

Physician Fee

Preston Crossing Facility Fee

Medical City Plano Hospital Facility Fee Call (800) 980-5794 CPT Code for EGD 43239, Colonoscopy 45380, ERCP 43261

Please be aware that you may also receive a bill from the anesthesiologist and the pathologist if any biopsies are done or if any polyps are removed.

We require a 48-hour cancellation notice or you may be charged $50.00 for no show or late cancellation.

If you have any questions, please feel free to contact our office at (972) 867-0019.

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

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Procedure Form

Please be aware that you may also receive a bill from the anesthesiologist and the pathologist if any biopsies are done or if any polyps are removed.

We require a 48-hour cancellation notice or you may be charged $50.00 for no show or late cancellation.

Digestive Health Associates of Texas

Sindhu Abraham, M.D.