Returning Patient Questionnaire

Returning Patient Questionnaire

If any information changed since your last visit, please be sure to update it below.
Name*

First NameMiddle NameLast Name
Date of Birth *

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
EmailSMS Text Message
EmployedFull-time StudentPart-time StudentOther
Insurance Information

Fill out if your insurance has recently changed
Primary Carrier
Member ID
Group Number
Subscriber's Name

First NameLast Name
Subscriber's Date of Birth

MonthDayYear
Date
Subscriber's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship to Patient
Primary Pharmacy

If you have recently changed your pharmacy location, please fill out section below.
Pharmacy Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

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

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

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.
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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	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

Insurance Information