New Patient Registration Packet

Patient First Name

Patient Last Name

Date of Birth

Social Security Number

This information is encrypted

Best Contact Phone Number:

Is it ok to leave a voicemail with results or medical information?

Yes No

Email Address:

Mailing Address:

City:

State

Zip Code:

Emergency Contact Name/Relationship:

Emergency Contact Phone:

Please list the name and contact information of someone with whom you would like us to share your medical information (if applicable).

Insurance Information

Who is your Insurance Carrier?

(Please note that we are NOT in network with Traditional Medicaid, AmBetter, Superior Health Plan as Primary or Secondary Insurance))

Subscriber ID

Please upload an Image of the front your primary insurance card

Add file

Please upload a file

Please upload an image of the back of your primary insurance card

Add file

Please upload a file

Do you have an HMO Insurance plan? PLEASE NOTE THAT IF YOU HAVE AN HMO INSURANCE, YOU WILL NEED A REFERRAL AUTHORIZATION SENT FROM YOUR PRMARY CARE PROVIDER TO YOUR INSURANCE COMPANY IN ORDER FOR YOUR VISIT WITH US TO BE COVERED BY YOUR INSURANCE.

Yes

IF YES, PLEASE MAKE SURE YOU CONTACT YOUR PRIMARY DOCTOR'S OFFICE OR INSURANCE COMPANY AND MAKE SURE YOUR REFERRAL AUTHORIZATION IS COMPLETED BEFORE SEEING US. OTHERWISE, YOUR VISIT AND ALL TESTS MAY NOT BE COVERED BY YOUR INSURANCE, AND YOU WILL HAVE TO PAY OUT OF POCKET.

If applicable

Subscriber ID

Please upload the front your supplemental insurance card.

Add file

Please upload a file

Please upload the back your supplemental insurance card.

Add file

Please upload a file

Who is your Primary Care Doctor?

Please list your Primary Care Doctor's phone number.

If you have any previous endoscopy, colonoscopy, labs, or imaging records, please upload them here:

Add file

Please upload a file

Medical History:

What brings you in to see the Gastroenterologist?

Please list any other medical conditions:

Medications:

Name

Dosage

Frequency

Please list your pharmacy name and phone number:

Please list any food or medication allergies that you have (Write None if none).

Surgical History

Have you had any of the following Surgeries?

None

Gastric Bypass/Sleeve

Hiatal Hernia Repair

C-Section/Hysterectomy

Tummy Tuck

Gallbladder Removal

Vascular or Heart Surgery

Colon Resection or Colon Surgery

Please list any other surgeries not listed above:

Family History

Does/did your mother have colon cancer, colon polyps, gallbladder disease cancer, liver disease, stomach or pancreatic cancer?

Does/did your father have colon cancer, colon polyps, gallbladder disease or cancer, liver disease, stomach or pancreatic cancer?

Does/did your sibling(s) have colon cancer, colon polyps, gallbladder disease or cancer, liver disease, stomach or pancreatic cancer?

Does/did you children have colon cancer, colon polyps, gallbladder disease cancer, liver disease, stomach or pancreatic cancer?

Any other family history?

Social History:

Do you use any tobacco products?

Yes No

If so, what type?

Smoke

Such as Cigarettes, Cigars

Chew

Such as snuff, dip

How many packs per day?

Less than half 1 pack per day More than one pack per day

Do you vape or use electronic cigarettes?

Yes No

Do you drink any alcoholic beverages regularly?

Beer

Wine

Hard Liquor

None

How many drinks do you have per week?

None 1-2 3-4 More than 5 Drink everyday

Review of Systems

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