Patient Information

Once we receive this form, our physicians will review your information and provide instructions to our schedulers, who will contact you to schedule your colonoscopy directly at one of our facilities.

Today's Date

Name

Date of Birth

Mailing Address

Home Phone

Cell Phone (optional)

Work Phone (optional)

Preferred method of contact:

Home Phone

Cell Phone

Work Phone

Marital status

Single Married Divorced Widowed

Email address (optional)

Emergency Contact

Name

Relationship to Patient

Contact Number

Pharmacy

Pharmacy Name

Phone Number

City

State

Insurance Information

Primary Insurance

Subscriber/Member Number

Group Number

Subscriber Name

Subscriber DOB

Secondary Insurance

Subscriber/Member Number

Group Number

Subscriber Name

Subscriber DOB

Height

Weight

Allergies

Primary Care Doctor

Reason for colonoscopy

Screening, 45 or older

Family history of colon cancer or precancerous polyp

Previous colonoscopy showing polyps

If you have a family history of colon cancer, what relative?

Have you had a prior colonoscopy?

Yes No

If yes, where/when?

Medications

Do you take aspirin?

Yes No

OTC Pain medication?

Yes No

Diabetes medications?

Yes No

Plavix, Coumadin or other blood thinners?

Yes No

Please list any other medications that you take with their doses, and directions

Medical History

Do you have a diagnosis of sleep apnea?

Yes No

Please list chronic medical conditions that you have been diagnosed with:

Past Surgeries

Please list all prior surgeries

Have you had any excessive or prolonged bleeding from previous injury or surgery?

Yes No

Do you have any metal implants?

Yes No

Do you have a pacemaker or cardiac defibrillator?

Yes No

Please list any family history of medical conditions

Social History

Are you a current smoker?

Yes No

If no have you smoked in the past?

Yes No

History of Drug Use:

Yes No

Alcohol Intake

Caffeine Intake

Permission to discuss medical care:
The following individuals are allowed by the staff of Gastrointestinal Medicine Associates, to discuss any and all issues concerning my medical care. NOTE that unless Gastrointestinal medicine Associates is notified by you in person or by certified mail, the individuals listed for permission to discuss medical care shall remain in effect indefinitely (please list their name and your relation).

Name

Relation

Add More

When it is necessary to contact you by phone, i.e. to confirm or cancel an appointment, or give information to you regarding a booking or test that our office has scheduled on your behalf etc; may we call the telephone numbers that you have provided, and if you are not available may we:

Signed

Patients with and without Health Insurance

I hereby authorize Gastrointestinal Medicine Associates, Inc., to release information to my insurance carrier(s) regarding my medical services and treatment in order to file a claim. I hereby assign all payments for medical services rendered to myself and dependents. I understand that I am financially liable for any co-pays, cost share, deductible, or co-insurance rendered to myself or dependents. I am responsible to pay within 30 days of my first bill or I will be subject to a 1.5% interest charge per month. If it becomes necessary to file suit to collect this bill, I agree to pay court costs and reasonable attorney fees to the extent permitted by law. Consequently, If I am uninsured, I understand that I am financially responsible for any and all services rendered to me by Gastrointestinal Medicine Associates, Inc. Payment is due at the time of service unless other arrangements have been made. I am responsible to pay within 30 days of my first bill or I will be subject to a 1.5% interest charge per month. If it becomes necessary to file suit to collect this bill, I agree to pay court costs and reasonable attorney fees to the extent permitted by law. A copy of this signature is valid as the original.

Signed

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