New Patient Information

Patient Interview Form

First Name

Last Name

MI:

Date of Birth

SSN:

Mailing Address:

City:

State:

Zip:

Primary Phone:

Secondary Phone:

Primary Care Physician

Phone:

Height:

Weight:

Person(s) to whom WGA may disclose/discuss my Personal Health Information / PHI:

Add Person

I hereby assign, transfer, and set over to Waco Gastroenterology Associates, PA (WGA) all of my rights, title, and interest to my . medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization will remain valid until I revoke it in writing. I understand that I am financially responsible for all charges whether or not they are covered by insurance. I request and give my consent to WGA to provide and perform such medical services as are considered necessary of beneficial by my healthcare provider for my health and well-being. I acknowledge WGA makes no representations, warranties or guarantees as to the results or cures. WGA has made available to me a copy of its Notice of Privacy Practices, Patient Rights, and Responsibilities and Patient Financial Policy and agree to abide by such policies. A photocopy, facsimile or digital copy of this document is valid as the original.

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

Signature:

Date

Patient Information

Email

Please check one as your preferred email for communications

Personal Work

Personal

Work

Contact Preference

Cell phone Email Telephone call - Home Portal Message Patient declines to specify

Insurance card

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Please upload a file

Diagnostic Studies/Test

None

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Previous Procedures

None

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Any Upcoming Procedures?

Yes No

When?

Current Medications

None

Add Additional Medications

Consent to Import Medication History

I consent to obtaining a history of my medications purchased at pharmacies.

Yes No

Past or Present Medical Conditions

None

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Social History

Occupation

Number of Children

Alcohol

Caffeine

Tobacco

SMOKING STATUS

Current every day smoker

Current some day smoker

Former smoker

Never smoker

Smoker, current status unknown

Light tobacco smoker

Heavy tobacco smoker

Unknown if ever smoked

Drug Use

Exercise

Review Of Systems

None

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Do you have a preferred pharmacy?

Consent to Share Data

I consent to having my medical and demographic information shared with other health care entities.

Yes No

Reminder Preference

I would like to receive preventive care and follow up care reminders.

Yes No

Reviewed with

Patient

Parent

Guardian

Not Present

Your information will be encrypted.