New Patient Registration and Medical History Form

Patient Questionnaire
Which physician are you scheduled to see?
Which physician referred you to our office for consultation?
Who is your primary care physician?
Presenting Complaint
Briefly describe the reason for your visit to Premier Gastroenterology.*

Rows	Yes	No	Date
Have you ever had an upper GI series or gastroscopy?

Medications
I currently take no medications

List all prescription, over the counter and herbal medications you are taking including the dosage or number of pills per day.

Rows	Medication Name	Dose	Frequency
Medication 1
Medication 2
Medication 3
Medication 4
Medication 5
Medication 6
Medication 7
Medication 8
Medication 9
Medication 10
Medication 11
Medication 12
Medication 13
Medication 14

Drug Allergies
I do not have any drug allergies.

List all medications to which you are allergic and the kind of reaction you experienced.

Rows	Allergy	Reaction
Allergy 1
Allergy 2
Allergy 3
Allergy 4
Allergy 5
Allergy 6
Allergy 7
Allergy 8
Allergy 10

Standard Authorization of Use and Disclosure of Protected Health Information

Please read carefully
Date*

MonthDayYear
Date
Patient Name: First Name* Last Name* DOB: Date*
This Standard Authorization gives the doctors and staff of Premier Gastroenterology your permission to speak to or give written documentation about your medical health information to the person(s) you have designated.
Who Can Receive and Use the Health Information:

Please fill this section out
Name:   First Name   Last Name   Relationship:   Type a label

Phone:   Area Code   Phone Number

Name:   First Name   Last Name   Relationship:   Type a label

Phone:   Area Code   Phone Number

Name:   First Name   Last Name   Relationship:   Type a label

Phone:   Area Code   Phone Number
Disclosure
All health informationProgress NotesLab ResultsBilling InformationProcedure and pathology reportsDiagnostic and Radiology report & imagesOther
RIGHT TO REVOKE: I understand that I can withdraw my permission at any time by giving written consent.

SIGNATURE AUTHORIZATION: I have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign form does not stop disclosure of health information tha thas occured prior to revocation or that is otherwise permitted by law without my specific authorization, including disclosures to other covered entities as provided by Texas Health & Safe Code 181.154(c) and/or 45C.F.R. 164.506(a)(1). I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipeint and may no longer be protected by federal or state privacy laws.
Signature of Patient or Guardian*

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Date

MonthDayYear
Date

Please Read Carefully

AUTHORIZATION FOR RELEASE OF INFORMATION FOR BILLING PURPOSES
I hereby authorize Premier Gastroenterology to furnish any information or to obtain any information necessary for third-party claim submission and/or payment for services. I authorize payment of third party benefits to Premier Gastroenterology, (Kevin T Marks MD PA) for Medical services provided. I understand that I am responsible to pay Premier Gastroenterology for all services rendered. Additionally, there is a fee of $50 for any no show or late cancelation, less than 48 hours prior to your scheduled office appointment.
Signature of Patient*

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Should be Empty:

Rows	Yes	No	Date
Colonoscopy
Flexible Sigmoidoscopy
Barium Enema
Stool Test for Blood (Hemoccult)
Prostate Exam and PSA (Blood Test)

Rows	Yes	No	Date
Influenza (Flu)
Pneumococcal
Hepatitis A
Hepatitis B
COVID-19

Rows	Check surgeries that apply to you	Date of surgery
Appendectormy
Cancer
Diverticular disease
IBD (Chron's, Ultcerative Colitis)
Bleeding
Obstruction
Performation
Hemorrhoidectomy

Rows	Check surgeries that apply to you	Date of surgery	Type of surgery (ONLY for Bariatric)
Lap Nissen
Ulcer disease
Cancer
Bariatric (weight loss surgery)

Rows	Check surgeries that apply to you	Date of surgery	Fill in Other row
Pancreatic Surgery
Liver Surgery
Hysterectomy
Cholecystectomy (Gallbladder removal)
Other

Patient Registration & Medical History

Please Provide a Photo of Your Driver's License

Emergency Contact

Responsible Party

Insurance Information

Pharmacy

Secondary Insurance Carrier

Patient Questionnaire

Presenting Complaint

Review of Systems

Healthcare Maintenance

Past Medical History

Past Surgical History

Family History

Social History

Medications

Drug Allergies

Standard Authorization of Use and Disclosure of Protected Health Information

Who Can Receive and Use the Health Information:

Disclosure

Please Read Carefully

Rows	Check which apply	Relative	Age
Colon Polyps
Colon Cancer
Liver Disease
Diabetes

Rows	Check that which apply	Relative	Type
Heart Disease
Other Cancers
Other Cancers
Other Illnesses
Other Illnesses