Gastro Health & Nutrition Fields marked with an * are required Patient's Information Last Name : * First Name : * Address : * City : * State : * Zip : * Date of Birth : * Social Security # : Race : Ethnicity : Home Phone: * Cell Phone: Driver’s License #: Email: * Do you have Advanced Directives? Yes No Pharmacy Name & Address: * PATIENT'S EMPLOYER INFORMATION Patient's Employer Information Company Name: Company Address: City: State: Zip: Phone: EXT: Occupation: Insurance Information Insurance Information Insurance Name: Policy Number: Group Number: Authorization Number (if required): Exp Date: Second Insurance Name: Policy Number: Group: EMERGENCY CONTACT Emergency Contact Name: * Relationship: * Phone: * Address: * City: State: Zip: PERMISSION SHEET PERMISSION SHEET I HTML , give permission to my physician at Gastro Health & Nutrition to discuss and/or release any medical information concerning my healthcare to the following family members/friends. I am aware that I may change this permission form at any time. 1 (FAMILY/FRIEND FULL NAME) (FAMILY/FRIEND FULL NAME) Relationship: Phone: 2 (FAMILY/FRIEND FULL NAME) (FAMILY/FRIEND FULL NAME) Relationship: Phone: 3 (FAMILY/FRIEND FULL NAME) (FAMILY/FRIEND FULL NAME) Relationship: Phone: I give permission to release appointment information to whoever answers the phone at my listed phone number(s): YES / NO Yes No Patient Signature * Interpretive Service Needs: Interpretive Service Needs: Primary Language: Interpreter Services Required: Yes No HTML Assignment of benefits: I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, private insurance and any other health plan to the physician/facility on record. A photocopy of this assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize said assignee to release all information necessary to secure the payment.Authorization of treatment: I hereby authorize the physician of record, and associates to treat the above patient. Patient Signature: * Date: * Please correct errors before submitting this form. If you are a human seeing this field, please leave it empty. PDF Form Download
