Registration Packet Procedures

Welcome to East Bay Center for Digestive Health

EBCDH is the largest single specialty gastroenterology group practice in the East Bay and comprises seven Board certified gastroenterologists with first rate clinical training and a dedication to providing excellent diagnostic and clinical care. We also have a certified Nurse Practitioner and certified Physician Assistant who each have over 10+ years of experience in the field of Gastroenterology. We are committed to exceeding your health care expectations.

You have been directed to this form because your primary care physician has referred you to our office and you are scheduled for an endoscopic procedure.

Your colonoscopy and/or upper endoscopy will be performed at East Bay Endosurgery Center, a state of the art facility located in our building in Suite 135. Please see the instructions below for completing your
REGISTRATION FORMS.

Please complete and submit this registration form online at least 2 weeks prior to your procedure.

**OF NOTE – these forms are separate and in addition to any information provided on the Patient Portal**

It is very important that we review your medical history prior to your procedure to avoid any late cancellations due to unknown medical conditions.

If you have not completed this online form prior to your procedure, you will be asked to complete paper forms at the time of your visit. Depending on your medical status, your procedure may need to be rescheduled or even cancelled.

If you are driving, please allow time to find parking.

If you have any additional questions, do not hesitate to call your Procedure Coordinator at the extension provided on your procedure instructions.
Patient Name: *
Sex: *

Male Female
Date of Birth: *

Month Day Year
Email: *
Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Mobile Phone: *
Home Phone: *
Other Phone: *
SSN#: *
Language: *
Race/Ethnicity: *
Primary Insurance: *
ID# *
Are you the subscriber for this insurance plan? *

Yes No
If no, who is? (Name) *
If no, who is? (DOB) *

Month Day Year
Secondary Insurance: *
ID# *
Are you the subscriber for this insurance plan? *

Yes No
If no, who is? (Name) *
If no, who is? (DOB) *

Month Day Year
Emergency Contact (Name): *
Emergency Contact (Phone #): *
CONSENT TO THE USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS

I understand that as a part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. EBCDH, Inc. will use and disclose my protected health information (“Health Information”) as defined by federal and state law, in the manner described below:
- A basis for planning my care and treatment.
- A means of communication among the many healthcare professionals who contribute to my care.
- A source of information for applying my diagnoses and surgical information to my bill.
- A means by which a third party payer can verify that services billed were actually provided.
- A tool for routine healthcare operations such as assessing care quality and reviewing the competence of healthcare professionals.
I understand that I have the right:
- To request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or healthcare operations and that the organization is not required to agree to the restrictions requested.
- To revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon.
Any and all of the following Health Information may be disclosed by EBCDH, Inc. on my behalf below for the follow reasons:
Medical Information can be discussed with: *

Patient only Family/Friend Spouse/Significant Other
Family/Friend Name: *
Spouse/Significant Other Name: *
Other Representative *
Billing Information and attempt to collect payment can be discussed with: *

Patient only Family/Friend Spouse/Significant Other
Family/Friend Name: *
Spouse/Significant Other Name: *
Other Representative: *
Detailed message regarding test results can be left on answering machine: *

Yes No
At this phone number only: *
It is okay to communicate via email via my Patient Portal: *

Yes No
Email Address: *
Signature of Patient or Legal Rep: *

Clear
Witness Signature: *

Clear
Patient Name:
Date Of Birth:

Month Day Year
Referring MD:
Pharmacy/Phone#:
Main Reason For Consultation Today (Chief Complaint):
Height: *
Weight: *
Check if you have any of the following:
Current Or Chronic/Ongoing GI Conditions. Please List Dates:

Stomach Ulcers Colon Polyps Diverticulosis Gallstones Colitis Crohn’s Irritable Bowel Syndrome Colon Cancer Hepatitis (inflammation of the liver, sometimes from a virus) History of GI infection(s)
Stomach Ulcers (date):
Colon Polyps (date):
Diverticulosis (date):
Gallstones (date):
Colitis (date):
Crohn’s (date):
Irritable Bowel Syndrome (date):
Colon Cancer (date):
Type:

A B C
Which GI infection(s)?
Previous GI Procedures Or Imaging:

Endoscopy of the Stomach Colonoscopy Sigmoidoscopy in the past 5 years Liver Biopsy Abdominal Ultrasound
Endoscopy of the Stomach (most recent date):
Colonoscopy (most recent date):
Sigmoidoscopy in the past 5 years (most recent date):
Liver Biopsy (most recent date):
Abdominal Ultrasound (most recent date):
GI Surgery:

Gallbladder surgery Appendectomy Other
All Other Surgeries:
Current Or Chronic/ongoing Medical Conditions:

Heart Disease Angina MI Cardiac Stent/Valve Replacement Pacemaker Defibrillator Arrhythmia Valvular Disease Stroke Seizures DVT/PE Sleep Apnea Obesity Diabetes High Cholesterol High Blood Pressure Arthritis Gout Kidney Disease Kidney Dialysis Blood transfusions HIV Cancer Immunologic Disorder COPD Asthma Tuberculosis Bleed/Clot Disorder Psychiatric Other
MI (date):
Stroke (date):
DVT/PE (date):
Obesity (lbs):
Cancer (type):
Other medical conditions:
Drug Allergies (medicines, iodine, or radiology contrast):
Family History
Check if your parents, grandparents, brothers, sisters or children have or had any of the following:

Liver disease Hereditary diseases Colon cancer Colon polyps Other cancers
Hereditary diseases (list)
Colon polyps (list relationship, maternal/paternal, and age at diagnosis if known)
Colon cancer (list relationship, maternal/paternal, and age at diagnosis if known)
Other cancers (list relationship, maternal/paternal, and age at diagnosis if known)
Social History
Currently disabled Current smoker Former smoker Never smoked Current drinker (alcohol) Don’t drink alcohol Intravenous drugs not prescribed by a physician or other street drugs No IV or street drugs Born outside the US?
Any Mobility Impairments? (i.e. wheelchair)
Current smoker (how many per day)?
Former smoker (year quit)?
Current drinker (alcohol) how much per week?
Born outside the US? (which country)?
Review Of Systems

In the last 6 months have you experienced any of the following? Do you currently have?

General
Fever/Chills?

Yes No
Unintentional Weight Loss?

Yes No
Fatigue / Tire Easily?

Yes No
Fever / Chills (Date of last Occurrence)?
Unintentional Weight Loss (Lbs since when)?
Fatigue / Tire Easily (Date of last Occurrence)?
Eyes/Mouth/Throat
Eye Inflammation / Redness?

Yes No
Non-healing Mouth Sores?

Yes No
Sour Taste In Your Mouth?

Yes No
Stomach Contents in Your Mouth?

Yes No
Sore Throat?

Yes No
Hoarse Voice?

Yes No
Severe Tooth Decay?

Yes No
Eye Inflammation / Redness (Date of last Occurrence)?
Non-healing Mouth Sores (Date of last Occurrence)?
Sour Taste in Your Mouth (Date of last Occurrence)?
Stomach Contents in Your Mouth (Date of last Occurrence)?
Sore Throat (Date of last Occurrence)?
Hoarse Voice (Date of last Occurrence)?
Severe Tooth Decay (Date of last Occurrence)?
Cardiac
Chest Pain Or Pressure?

Yes No
Palpitations (sensation of heart beating in chest)?

Yes No
Chest Pain Or Pressure (Date of last Occurrence)?
Palpitations (sensation of heart beating in chest) (Date of last Occurrence)?
Respiratory
Shortness of Breath?

Yes No
Wheezing / Asthma?

Yes No
Shortness of Breath (Date of last Occurrence)?
Wheezing / Asthma (Date of last Occurrence)?
Gastrointestinal
Heart Burn / Acid Reflux?

Yes No
Difficult / Painful Swallowing?

Yes No
Nausea / Vomiting?

Yes No
Poor Appetite?

Yes No
Diarrhea (loose or frequent stools)?

Yes No
Constipation?

Yes No
Bloody or Black Bowel Movements (on Iron? Pepto Bismol?)

Yes No
Vomiting Blood?

Yes No
Significant Abdominal Pain Or Cramping?

Yes No
Heart Burn / Acid Reflux (Date of last Occurrence)?
Difficult / Painful Swallowing (Date of last Occurrence)?
Nausea / Vomiting (Date of last Occurrence)?
Poor Appetite (Date of last Occurrence)?
Diarrhea (loose or frequent stools) (Date of last Occurrence)?
Constipation (Date of last Occurrence)?
Bloody or black bowel movements (Date of last Occurrence)?
Vomiting Blood (Date of last Occurrence)?
Significant Abdominal Pain Or Cramping (Date of last Occurrence)?
Musculoskeletal
Joint Pain?

Yes No
Back Pain?

Yes No
Joint Pain (Date of last Occurrence)?
Back Pain (Date of last Occurrence)?
Skin
Rash?

Yes No
Jaundice (yellowing of the skin or eyes)?

Yes No
Easy Bruising or Bleeding?

Yes No
Rash (Date of last Occurrence)?
Jaundice (Date of last Occurrence)?
Easy Bruising or Bleeding (Date of last Occurrence)?
Neurological
Trouble Thinking Clearly?

Yes No
Fainting?

Yes No
Trouble Thinking Clearly (Date of last Occurrence)?
Fainting (Date of last Occurrence)?
Psychological
Stress at Work or Home?

Yes No
Feeling Anxious or Depressed?

Yes No
Stress at Work or Home (Date of last Occurrence)?
Feeling anxious or Depressed (Date of last Occurrence)?
Blood/Lymph
History of Anemia?

Yes No
Bleeding or Clotting Disorder?

Yes No
History of Anemia (Date of last Occurrence)?
Bleeding or Clotting Disorder (Date of last Occurrence)?
PATIENT MEDICATION LIST

So that we may maintain the highest quality in care and safety,
please fill in ALL MEDICATIONS that you take.

Please be sure to include all asthma, heart and blood pressure medications, any narcotics you may take (Percocet, etc.),
and any over the counter or herbal medications, medical creams or sprays and any supplements
Name:
Date:

Month Day Year
Patient Signature:

Clear
I do not take any medications at this time.
Name:
Date:

Month Day Year
Patient Signature:

Clear
East Bay Center for Digestive Health Medical Associates, Inc.
Paul S. Chard, M.D., Ph.D., E. Michael Darby, M.D., Susie Ng Cohn, M.D.,
Neil H. Stollman, M.D., Liana Vesga, M.D., Silvia M. Villagomez, M.D., Danny Wu, M.D.
Direct Referral Screening Colonoscopy
General Information and Colonoscopy Consent Form

Background: In the United States, colorectal cancer (CRC) is the second leading of cancer deaths (lung cancer is the
leading cancer). Approximately 150,000 new cases are diagnosed in the US every year. Screening has been shown to
decrease death from CRC. Your primary care physician has referred you to have a screening colonoscopy.

What is it? Colonoscopy is a procedure that allows your physician to see the inside of your colon and rectum using a
flexible tube (about the width of your index finger) containing a light and camera. This technology gives the physician the ability to take biopsies and remove suspicious findings if any are seen.

What to expect: On the day before the procedure you will not be allowed to eat ANY solid foods. However, you will be allowed to have clear liquids. Sometime during the DAY BEFORE the procedure you will begin a bowel preparation to “clean out” your colon. Please read the bowel preparation instructions for specific further details – these are sent to
you once the procedure is scheduled.

Because this test can be mildly uncomfortable, you will be receiving anesthesia to make you sleepy during the exam, but you will not lose consciousness and will be breathing on your own. Most patients do not recall having the procedures done because the sedatives can impair short-term memory. The procedure typically takes less than 30 minutes. Recovery time is typically less than 60 minutes. Due to the anesthesia you will be receiving, you will not be allowed to drive home from the procedure. You will need a responsible adult to take you home. You cannot take a taxi or other service, i.e. Uber.

You can have a light meal after your procedure and the remainder of the day should be spent resting. Due to the anesthesia, your judgment might be impaired for the remainder of the day, so you shouldn’t make any big decisions or operate machinery. The next day you should be back to normal.

RISKS, BENEFITS, AND ALTERNATIVES: The risk of serious consequence from screening colonoscopy is very low.
Potential serious complications include, but are not limited to bowel perforation (approximately 1 in 1,000), a small risk of heavy bleeding after removal of polyps (approximately 1 in 1,000) and death (approximately 1 in 20,000). Other possible risks include adverse reaction to sedation, infection, missed lesions and cardiopulmonary compromise. Alternatives to a screening colonoscopy include a radiology test, a flexible sigmoidoscopy, yearly stool test cards, which check for blood, and choosing not to have investigation performed.

If you have more specific questions regarding the procedure itself or the risks, benefits and alternatives, you are advised to make an office visit to fully answer all your questions before scheduling the procedure.
Name:
Patient Signature:

Clear
Date:

Month Day Year
NOTIFICATION

In the event that you have a procedure scheduled with one of our physicians at East Bay Endosurgery Center:

Please be informed that the physician who is rendering services to you has ownership interest in this facility.

East Bay Endosurgery was designed and built specifically to provide outpatient GI endoscopy procedures and to meet the needs of our community. Our staff consists of licensed nurses and certified technicians who are specifically qualified to assist in endoscopic procedures. The combination of our physicians and this group of dedicated professionals ensures the highest quality health care for our patients. By signing this document you indicate that you are aware of their ownership interest and have been offered the opportunity to be treated elsewhere, but have decided to have your procedure performed at East Bay Endosurgery.

Though the physician may be contracted with your specific health plan, in some cases the facility may not. The insurances listed below are contracted with the facility;

Aetna, Alameda Alliance, CHCN (except Blue Cross), Blue Cross, Blue Shield, Cigna, First Health, Health Net, MEDI-CAL, Medicare, Pacific Care, United Health Care, PHCS, Great West, Interplan, Beech Street, Tricare, Three Rivers Provider Network, PHCS, GEHA, UMR, Humana, APWU and Multiplan.

If your particular insurance is not listed, then it may not be contracted with the facility. Many insurance plans offer out-of-network benefits which allow you to use a nonparticipating facility, while others do not. In either case, East Bay Endosurgery will strive to keep your out-of-network expenses competitive with the rates charged by “in-network” hospital facilities. Please be aware that deductibles and co-insurances are due at the time services are rendered to you.

As is customary, insurance plans make a distinction between the fee the physician charges and the fee the facility charges. Per standard billing practices, your insurance will be billed two separate claims for these services.

When East Bay Endosurgery submits a claim to a non-contracted insurance, it is possible they will forward the payment directly to you because it is not “in-network”. We are asking for your cooperation in making this process run smoothly. When you receive the payment for the services provided, please sign and forward the payment to our office. Please remember that you are ultimately responsible for all charges. Should you have any questions regarding a bill for the doctor’s fee, please contact our billing office at (510) 763-3332. Should have you any questions regarding a bill for the facility fee, please call (510) 893-1600 #3.
Date:

Month Day Year
Patient Signature:

Clear
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, have received a copy of the Notice of Privacy Practices for East Bay Center for Digestive Health.
Name:
Date:

Month Day Year
Patient Signature:

Clear
ACKNOWLEDGEMENT OF RECEIPT OF FINANCIAL POLICY
I, have received a copy of the Financial Policy for Practices for East Bay Center for Digestive Health.
Name:
Date:

Month Day Year
Patient Signature:

Clear
Should be Empty: