The Gastroenterology Group New Patient Form

DOUGLAS JAY SPRUNG MD., FACG., FACP.

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Name *
Date of Birth *
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ÅÅÅÅ
Last 4 Digits of you Social Security:
Phone Number *
Home Address (Street, City, State, Zip) *
Email Address
Sex *
Marital Status *

If The Patient Is A Minor:

Who is responsible for the bill and what is the relationship of that person? Please also provide: Address of Responsible Party.

EMERGENCY CONTACT INFORMATION:

Please include Name, Relationship, Phone Number:

INSURANCE INFORMATION:

List your current Insurance Provider and Member ID

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Please list your Pharmacy name and pharmacy's phone number:

Primary care physician Name and Phone Number:

Are you been vaccinated for Covid-19?

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If you answered "yes" to being vaccinated for Covid-19, please list the date(s) of your vaccination(s) and the manufacturer (Johnson & Johnson, Moderna, Pfizer):

Why are you here to see the doctor today?

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Referred by: *
Obligatorisk
Have you had any prior GI tests done? *

If you answered "yes" to having any prior GI tests, please list the type of test and the date the test was done:

Medications you are allergic to (if none, put N/A):

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Food Intolerances (if none, put N/A):

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Specify any foreign travel in the last 6 months (if none, put N/A):

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Do you smoke?

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If you answered "Previously", when did you quit?

Do you drink alcoholic beverages?

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If you answered "Yes", how frequently do you consume alcohol?

Do you drink coffee?

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Are you on Aspirin?

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Do you take any blood thinners?

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Do you have stents?

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Do you have artificial joints?

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If you answered "Yes" to artificial joints, which and when did you have artificial joints?

Prior GI Tests (if you select any boxes, please see below):

If you selected any Prior GI Tests boxes, please indicate which test you had, and when you had that test:

FAMILY HISTORY (Please select if maternal/paternal relation below)

If you selected "Other Cancers", please indicate what type and if it is on your maternal or paternal side:

SURGERY AND HOSPITALIZATIONS REVIEW

List all Hospitalizations, Operations and Injuries in the last 10 years (please include the hospital, the reason for the visit, and the year):

MEDICATION LIST AND PRESCRIPTIONS:

Please list the Medication, the Dosage/Strength, and Number of Times Taken Daily for each medication:

OVER THE COUNTER MEDICATIONS / VITAMINS / SUPPLEMENTS / HERBS:

Please list the Medication etc., the Dosage/Strength, and Number of Times Taken Daily for each medication etc.:

PAST MEDICAL HISTORY: 

Check the box(es) of a past problem:

SYSTEM REVIEW: 

Check the box(es) of a past problem:

AUTHORIZATION TO RELEASE OR USE INFORMATION FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS

I hereby authorize the release or use of my protected health information (“PHI”) and medical record information by The Gastroenterology Group (the “Practice”) in order to carry out treatment, payment, or health care operations. These disclosures may be by phone, mail, fax or electronic transmission. You should review the Practice’s Notice of Privacy Practices for a more complete description of the potential release and use of such information, and you have the right to review such Notice prior to signing this Consent Form.

If you allow a third party other than our practice physician or staff to be in the exam room while our physician or staff is examining your or discussing your care, treatment or medical condition with you, by signing this Consent form you are consenting to the disclosure of your PHI to that third party.

We reserve the right to change the terms of its Notice of Privacy Practices at any time. If we do make changes to the terms of its Notice of Privacy Practices, you may obtain a copy of the revised Notice.

You retain the right to request that we further restrict how your protected health information is released or used to carry out treatment, payment, or health care operations. Our practice is not required to agree to such requested restrictions; however, if we do agree to your requested restriction(s), such restrictions are then binding on the Practice.

I acknowledge and agree that the Practice may disclose my protected health information and medical record information to the following individuals: (please initial on the line and write in name of individual i.e. Parent, Spouse, Child, Guardian, Other)

(Initials that are typed-in will be accepted as a signature)

I agree that the Practice may also disclose the following types of information contained in my medical record (please check the appropriate categories listed below):

I agree and consent to the Practice releasing information to me in the following alternative manner(s) (please check the appropriate spaces below)

At all times, you retain the right to revoke the consent. Such revocation must be submitted to the Practice in writing. The revocation shall be effective except to the extent that the Practice has already taken action based on the prior Consent. The Practice may refuse to treat you if you (or an authorized representative) do not sign this Consent Form. If you (or authorized representative) sign this Consent and then revoke it, the Practice has the right to refuse to provide further treatment to you as of the time of revocation (except to the extent that the Practice is required by law to treat individuals).

I have read and understand the information in this consent. I am the patient or the authorized party to act on behalf of the patient to sign this document verifying consent to the above terms. By signing below, I acknowledge and agree to the above conditions.

(Your typed-in name will be accepted as a signature)

ACKNOWLEDGEMENT FORM

Our notice of Privacy Practices provides information about how we may use and release protected health information about you. You have the right to review our Notice before signing this form. As provided in our Notice, the terms of our Notice may change. If we change our Notice, you may obtain a revised copy by writing our practice or requesting a copy from our front desk staff.

You have the right to request that we restrict how protected health information about you is used or released for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound by our agreement.

By signing this form, you consent to our use and release of protected health information about you for treatment, payment and health care operations as described in our Notice. You have the right to revoke this consent, in writing, except where we have already made releases in reliance on your prior consent.

(Your typed-in name will be accepted as a signature)

I UNDERSTAND THAT IF I DO NOT SHOW, RESCHEDULE, OR CANCEL MY APPOINTMENT WITHOUT 24 HOURS NOTICE, I WILL BE RESPONSIBLE FOR A CHARGE OF $40.00. IN ADDITION, IF I AM 15 MINUTES OR MORE LATE I WILL BE MARKED AS A NO SHOW.

(Your typed-in name will be accepted as a signature)

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