New Patient Form

PATIENT ENROLLMENT

Name

Date of Birth

Address

Apt./Floor

City

State

Zip Code

Telephone # (Home)

Cell #

SS #

Marital Status

Race

Occupation

Employer Name

Address

City

State

Zip Code

Telephone

Emergency Contact

Telephone

Relationship

Referring MD

Primary Care Provider

Allergies

Primary Insurance Information

Company

ID #

Group #

Claims Mailing Address

Subscriber Name (if other than the patient)

Date of Birth

Address

City

State

Zip

Telephone

SS#

Relationship to Patient

Secondary Insurance Information

Company

ID #

Group #

Claims Mailing Address

Subscriber Name (if other than the patient)

Date of Birth

Address

City

State

Zip

Telephone

SS#

Relationship to Patient

I have been given information on privacy, patient rights and advanced directives by my provider and I understand that my provider is one of the owners of Garden State Endoscopy & Surgery Center.

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.

Patient Signature

Date

Please provide your insurance card(s) and picture I.D. and proof of address to the receptionist. Than you very much.

PATIENT CONFIDENTIALITY

Patient confidentiality is a prime concern in this office. Please indicate below with whom our office can or cannot leave a message.

Please check one where appropriate

Spouse

Yes No N/A

Phone #

Children

Yes No N/A

Phone #

Answering Machine

Yes No N/A

Phone #

Email Address

Yes No N/A

Phone #

(Your address if yes)

Are you able to receive calls at your workplace?

Yes No

May we call you at your workplace and state who is calling?

Yes No

Due to confidentiality regulations, should a family member, friend, or relative contact our office, we are not liberty to discuss your situation unless we have a permission from you - the patient.

Please check with whom we may discuss your situation.

Spouse

Yes No N/A

Children

Yes No N/A

Other

Yes No N/A

Children &/ or Significant Others

Add Children &/ or Significant Others

Please Sign

Date

Witness

Date

MEDICATION LIST

Patient's Name

Date

Pharmacy

Pharmacy Address

Phone

Allergies

Add Medication

Attestation:

I verify that the list is complete and accurate to the best of my knowledge which I provided to be included in my medical record.

This list includes any over the counter medications and herbal supplements, as well as regular and occasionally used prescription drugs.

Patient Signature/Responsible Adult

Date

REVIEW OF SYSTEMS

Name

DOB

Date

Have you had any of these problems in the past six months?

General

Breast/lump/pain/mass.changes

Thyroid/neck cyst/mass

Fatigue

Loss of Appetite

Excessive Thirst/Hunger

Weight Loss

Night Sweats

Fever/Chills

Ear, Nose, Throat

Tooth abscess/gum infection

Hearing loss

Ringing in the ear

Nasal discharge

Nosebleed

Sinusitis

Throat infection/pain

Eye

Double vision

Ear pain/discharge

Blurry vision

Cataracts

Glaucoma

Dermatology

Skin rash/skin changes

Varicose veins

Musculoskeletal

Muscle Weakness

Joint/Muscle Pain

Back Pain

Cardiology

Shortness of Breath

Chest Pain

Palpitations

Leg Swelling

Gastrointestinal

Genitourinary

Enlarged lymph glands

Difficulty with urination

Blood in urine/changes in urination

Excessive vaginal bleeding

Pregnancies

Vaginal discharge

Penile discharge

Neurology

Headaches

Vertigo/dizziness

Loss of consciousness

Convulsions

Facial numbness/weakness

Abnormal skin sensation

Memory loss

Poor muscle strength

Psychiatry

Anxiety/depression/insomnia

Infectious

Contagious disease/STD/HIV/Hepatitis

Endocrine

Heat/Cold Sensitivity

Respiratory

TB Test

Wheezing/Respiratory sounds

Cough

Hay Fever

Coughing Blood

MEDICAL HISTORY

Name

DOB

Date

Please indicate if you've had any of the following illnesses or medical conditions:

Anemia

Yes No

Arthritis/Osteoporosis

Yes No

Diabetes

Yes No

Cancer

Yes No

Thyroid Disease

Yes No

Glaucoma

Yes No

Cardiac Disease/Valvular Disease

Yes No

Heart attack

Pacemaker or Defibrillator

Echocardiogram/EKG

Coronary Angioplasty

Coronary Bypass Surgery

Coronary Stent Placement

Cardiac Catherization

Valve Surgery

Emphysema/Bronchitis/Asthma

Yes No

Digestive Liver/Gall Bladder/Pancreas Disease

Yes No

Renal Disease

Yes No

Uterus/Ovarian/Cervix Disease

Yes No

Prostatic Disease

Yes No

Blood/Coagulation Disease

Yes No

Vascular Disease

Yes No

Hypertension

Yes No

AIDS/HIV/Infections

Yes No

Have you received blood transfusions

Yes No

Female (pregnant)

Yes No

Drug use/other remedies

Yes No

Other illnesses

Yes No

Surgical History

Surgeries

Family History

Liver/Intestine/Pancreas/Stomach/Biliary Cancer

Yes No

Your information will be encrypted.

New Patient Form - English

PATIENT ENROLLMENT

Primary Insurance Information

Secondary Insurance Information

PATIENT CONFIDENTIALITY

Please check one where appropriate

Please check with whom we may discuss your situation.

Children &/ or Significant Others

MEDICATION LIST

REVIEW OF SYSTEMS

Have you had any of these problems in the past six months?

MEDICAL HISTORY

Surgical History

Family History