Patient Information - Información del paciente

Last Name - Apellido

First Name - Nombre de pila

Middle Initial - Segundo nombre

Sex - el sexo

Male - Masculino

Female - Femenino

Date of Birth - Fecha de nacimiento *

Marital Status - Estado Civil

Single - Soltero/a

Married - Cosando/a

Social Security Number - Número de seguridad social

Email Address - Dirección de correo electrónico

Race

Ethnicity

Preferred Language - Idioma preferido

Street Address - Dirección

City - Ciudad

State - Estado

Zip Code - Código postal

Home Phone Number - Número del hogar

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Cell Phone Number - Número de celular

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Work Phone Number - Número de trabajo

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Occupation - la Ocupación

Spouse Name - Nombre del conyuge

Date of Birth - Fecha de nacimiento *

Phone Number - Número de teléfono

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Patient History - Physical Form

Patient Past Medical Historyc (Please check any medical problems you had in the past)

Anemia

Anticoagulation Therapy

Anxiety

Artheritis

Cancer

Cataracts

Chronic Lung Disease

Cirrhosis

Colon Polyps

Congestive Heart Failure

Coronory Heart Disease

Crohn's Disease

Deep Vein Thrombosis

Depression Mellitus

Fatty Liver

Fibroyalgia

GERD(Heartburn)

Heart Disease / Pacemaker

Hepatitis B

Hepatitis C

Hyperlipidemia (High Cholestrol)

Hypertension (High Blood Pressure)

Inflammatory Bowl Disease

Irritable Bowl Syndrome

Kidney Disease

Kidney Stone

Liver Disease

Myocardial Infarction (Heart Attack)

Osteoporosis

Pancreatitis

Primary Billiary Cirrhosis

Primary Scierosing Cholangitis

Rashes / Skin Problems

Renal Insufficiency

Sleep Apnea

Thyroid Disease

Ulcerative Colitis

Other

Specify

Past Surgical History

Check any surgeries you have had and date of surgery if you know it

Never had surgery

Appendectomy

Bariatric Surgery

Bowel Resection

Breast Surgery

Cholecystectomy (GallBladder Removal)

Colonoscopy

Upper Endoscopy (EGD)

Cosmetic Surgery

C-Section

Eye Surgery

Hepatobilliary Surgery

Hernia Repair

Hysterectomy

Kidney Transplant

Liver Transplant

Orthopedic Surgery

Sterilization Surgery

Vascular Surgery

Other

Specify

Family History

Check below to report problems your FAMILY MEMBERS have had

I was adopted so I do not know my Family History

Alcohol Abuse

Father Mother Father's Parent Mother's Parent Siblings Children

Breast Cancer

Father Mother Father's Parent Mother's Parent Siblings Children

Cancer

Father Mother Father's Parent Mother's Parent Siblings Children

Celiac Disease

Father Mother Father's Parent Mother's Parent Siblings Children

Colon Cancer

Father Mother Father's Parent Mother's Parent Siblings Children

Colon Polyps

Father Mother Father's Parent Mother's Parent Siblings Children

COPD Lung Disease

Father Mother Father's Parent Mother's Parent Siblings Children

Cystic fibrosis

Father Mother Father's Parent Mother's Parent Siblings Children

Diabetes

Father Mother Father's Parent Mother's Parent Siblings Children

Heart Attack

Father Mother Father's Parent Mother's Parent Siblings Children

High Cholestrol

Father Mother Father's Parent Mother's Parent Siblings Children

Hypertension

Father Mother Father's Parent Mother's Parent Siblings Children

Inflammatory Bowel Disease

Father Mother Father's Parent Mother's Parent Siblings Children

Irrtable Bowel Syndrome

Father Mother Father's Parent Mother's Parent Siblings Children

Kidney Disease

Father Mother Father's Parent Mother's Parent Siblings Children

Liver Disease

Father Mother Father's Parent Mother's Parent Siblings Children

Other

Specify

Medication

List current Medication , Dosage, Frequency and Indication

Pharmacy

Pharmacy

Location

Allergies

Pharmacy Phone Number - Número de teléfono

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Emergency Contact

Name/Nombre

Relational to Patient/Nombre

Phone Number - Número de teléfono

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Street Address - Dirección

City - Ciudad

State

Zip Code - Código postal

Primary Care Physician

Doctor Name/Nombre del medico

Phone Number - Número de teléfono

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Fax Number

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Street Address - Dirección

City - Ciudad

State

Zip Code - Código postal

Referring Physician

Doctor Name/Nombre del medico

Phone Number - Número de teléfono

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Fax Number

Please enter in the 123-123-1234 format - Ingrese en el formato 123-123-1234

Street Address - Dirección

City - Ciudad

State

Zip Code - Código postal

Financial Policy

The doctors and staff of Gastroenterology Consultants, CFL, PA would like to welcome you to our practice. We strive to provide you with excellent medical care and our goal is to make your visit as convenient as possible. We ask for help by understanding and cooperating with our financial policy.

Please read this policy and sign below confirming you understand the following:

All payments - Self pay fee, insurance co-payments, co-insurances and deductibles will be collected at the time of service. Payable by Cash, Check, Visa, MasterCard, Discover or American Express.

A return check will result in a $25 service charge and all future payments will be required in the form of Cash or Credit Card.

If you do NOT have your payment; your appointment may be re-scheduled

Payment in full of any past due balance is expected prior to being seen.

Our practice participates with several insurance companies; it is your responsibility to understand the requirements and covered benefits of your plan.

You are responsible for any non-covered and/ or denied claim; you will receive a statement of denied charges and payment is due in 30 days after the date of statement.

If you insurance policy requires a referral, it is your responsibility to contact your primary care physician and have a referral faxed to our office prior to appointment date.

It is your responsibility to notify our office of any changes to your insurance coverage, your address and telephone number

You are required to cancel your appointment 24 hours prior to the appointment time.

No shows and late cancellation are subject to a $50 cancellation charge for office visits and $100 cancellation charge for procedures.

We realize that temporary financial problems may affect timely payment of accounts. If such problem arise, we urge you to contact us promptly for assistance in the management of your account. Call 407292-1414.

I have read and understand the above financial policy and agree to meet all financial obligations.

Patient Name (Print):

Date :

Signature of Patient

ASSIGNIMENT OF INSURANCE BENEFITS

I hereby authorize direct payment of surgical/ medical benefits to Gastroenterology Consultants, for services rendered by him/her in person or under his/her supervision. | understand that | am financially responsible for any balance not covered by my insurance/s.

Espajiol: Por la presente autorizo el pago directo de beneficios medicos / procedimiento a Gastroenterology Consultants, por los servicios prestados por el / ella en persona o bajo su / su supervisidn. Entiendo que soy financieramente responsable de cualquier saldo no cubierto por mi seguro.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Gastroenterology Consultants to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefits.

Espaiiol: Por la presente autorizo Gastroenterology Consultants para liberar cualquier informacien medica 0 incidental que pueda ser necesario, ya sea para la atencien medica 0 en la tramitacien de solicitudes de eneficios financieros.

MEDICARE/ MEDICAID BENEFITS

| certify that the information given by me in applying for payment is correct. | authorize release of all records on request. | request that payment of authorized benefits be made on my behalf.

Espaiiol: Certifico que la informacidn dada por mi en la solicitud de pago es correcta. Autorizo la liberacien de todos los registros a peticien. Solicito que el pago de los beneficios autorizados se haga en mi nombre.

Patient Name (Print):

Date :

Signature of Patient