PGASC Appointment Request Form

Child's Name:

First NameLast Name

Date of Birth:

Gender:

Parent/Guardian Name:

Relationship to patient:

Has this patient been seen by our doctors at any time in the past?

Which physician are you requesting to see in our office? (Check one or more)

*Reason for seeing a gastroenterologist:

Referring physician's name:

Referring physician's phone number:

Please enter a valid phone number.Format: (000) 000-0000.

Please provide two phone numbers that we can contact you at to schedule your appointment:

Primary phone numberFormat: (000) 000-0000.

Secondary phone numberFormat: (000) 000-0000.

To help us in scheduling your appointment, please tell us if you have an HMO or PPO. Please note that for all HMO plans, a referral from your pediatrician and insurance authorization may be needed.

Please provide your email address:

example@example.com

Which clinic location do you prefer?

Please arrange for your referring doctor to FAX copies of your childs medical records to our office, including growth charts, all laboratory and x-ray reports related to current GI problem, and any other pertinent information prior to your appointment. Our fax number is 866-447-2930

No Doctor-Patient relationship exists until your child is seen in consultation by a provider in our office.

*Due to HIPAA regulations, please do not include any medical information that is beyond what is necessary for treatment and appointment request. You are authorizing the sharing of medical information between you and this medical office when you are requesting an appointment with our office.