Gastroenterology Consultants Gastroenterology I Hepatology I Endoscopic Ultrasound
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1 Gastroenterology Consultants Gastroenterology I Hepatology I Endoscopic Ultrasound Michele C. Woodley, MD Barry K. Abramson, MD Jonathan C. Seccombe, MD 3009 N. Ballas Road Suite 359C St. Louis, MO Phone: (314) Fax: (314) Exchange: (314) Dear Patient, We are sending paperwork for you to fill out prior to scheduling an office visit. We now have electronic medical records and must enter your information prior to any appointment so your electronic chart is ready to view the day of your visit. Please return this completed paperwork as soon as possible. After we receive your information, we can put you on a cancellation list to try to get you in sooner. WE MUST HAVE YOUR PAPERWORK RETURNED TO OUR OFFICE BEFORE ANY APPOINTMENT SO IT CAN ENTERED IN THE ELECTRONIC CHART. WE MUST HAVE ALL MEDICAL RECORDS PRIOR TO ANY APPOINTMENT. A MEDICAL RELEASE IS ENCLOSED FOR YOU TO SEND TO YOUR DOCTOR. IF WE DO NOT RECEIVE YOUR RECORDS PRIOR TO YOUR OFFICE VISIT, YOU MAY NEED A FOLLOW UP VISIT TO REVIEW RECORDS RECEIVED AFTER YOUR. INITIAL VISIT. Please call our office with any questions. Thank you. Gastroenterology Consultants
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3 Clinical Patient Information Demographic Information Allergies Social History Patient Name Allergy Reaction Tobacco o Never o Current o Former Packs/Day: Patient Date of Birth Alcohol o No o Yes Amount/Week: Reason for Visit Pharmacy Name: Phone: o Retail o Mail Order Medications Immunizations Medication Name Dose Directions Name Date (Month/Year) Tetanus Pneumovax TB (PPD) HEP A HEP B Active Chronic Problems Prior Surgeries and Past Medical Conditions (Month/Year) Tests / Diagnostic Screenings Test/Screening Date Results/Findings Doctor Performed Colonoscopy Colonoscopy Endoscopy Endoscopy Bone Density Family History Relationship Cancer (type) Intestinal Problem If deceased, cause of death (age) Comments Mother Father Sister Brother
4 AUTHORIZATION TO RELEASE MEDICAL RECORDS Patient Name Date of Birth I authorize (your doctor's name) to disclose the following medical information to: GASTROENTEROLOGY CONSULTANTS 3009 N. Ballas Road Suite 359C St. Louis, MO phone fax The authorization extends only to documents marked below: _Progress and Consult notes _H&P notes _X-Ray reports _GI scopes and Biopsies _Lab results _Other List other documents authorized Any and all records, whether written, oral or in electronic format are confidential and cannot be disclosed without any prior written authorization. A photocopy or fax of this authorization-is as valid as the original. I may revoke this authorization at any time except where information has already been released. This authorization is valid for one year from the date it is signed. Gastroenterology Consultants, physicians and all employees are hereby released from any legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. Patient's name Date Patient's Name Date
5 Gastroenterology Consultants Office of Drs. Michele C. Woodley, Barry Abramson and Jonathan Seccombe 3009 N. Ballas Road, Building C, Suite 359 St. Louis, MO Fax: MAP KEY Building C, C Garage Elevator 26 Exit 26 from ramp loops 26 back to enter Ballas Rd. Escalator Pedestrian Walkway Valet MBM 8/13/ 15 North Entry JESS G. HARMON DR. North Garage Entry BLDG. D 270 Exit 12 from 270 to 64/40 East C Garage BLDG. C C Entry C E COPELAND DR West Entry Main Tower Cancer and Infusion Center and ER ONLY East Entry EMERGENCY Cancer Infusion Center Night Entry 9 p.m. - 5 a.m. N BALLAS ROAD 12 BLDG. A Suite 359C BLDG. B A/B Entry Main Garage Clinical Learning Institute Goldfarb School of Nursing (Level 4) West Pavilion East Pavilion Hospital Main Entry Admitting / Lab Registration METROBUS Parking is available in the C Garage, the Main Garage and on the surface parking lots. Free Valet Parking (tips not accepted) available at Building A/B Entry and Main Entry. From Interstate 270 Take Interstate 270 to the Interstate 64/US Highway 40 exit east. Quickly and safely move to the far right lane (Ballas Road exit). Turn left (south) on Ballas Road, then turn right into the campus. From Interstate 64/US Highway 40 Take Interstate 64/US Highway 40 to the Ballas Road exit. Turn south on Ballas Road, then turn right into the campus.
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PATIENT INFORMATION FORM Name: E-Mail: New Patient? Previous Patient? Previous name if different: Age: Date of Birth: Social Security #: Sex: Female Male Marital Status: S M W D Home Address: City: State:
Emergency Contact Name: Relationship: Home #: ( ) Cell #: ( ) Alternate #: ( ) Pharmacy Information Pharmacy Name: Phone #: ( ) Location:
New Patient Office Information Last Name: First Name: Initial Date of Birth: SSN # Marital Status: Single Married Divorced Widowed Address: City: State: Zip: Gender: M Parent/ Legal Guardian if Patient
MRI Patient Screening and History
Griffin Imaging, LLC 220 Rock Street Griffin, GA 30224 (770) 229-4660 Fax:: (770) 229-4632 Specializing In Open MRI, CT & Ultrasound MRI Patient Screening and History Patient Information Sheet PATIENT
PAGE 1 0F 14. G:\MASTER documents to print out\new PATIENT QUESTIONNIRE & Patient Id - ADULT March 2016 ONLINE.doc
PAGE 1 0F 14 Keep this blank page if printing double sided PAGE 2 0F 14 The Surgery Amersham Health Centre Chiltern Avenue, Amersham, Bucks HP6 5AY Tel 01494 434344 : Fax 01494 733711 Dear Patient Thank
Counseling Center of Montgomery County
Counseling Center of Montgomery County 212 Conroe Drive (936) 760-1880 Office Conroe, TX 77301 (936) 760-2915 Office CCMC@CounselingCenterMoCo.com (936) 760-9101 Fax CHILD/ADOLESCENT PSYCHOSOCIAL HISTORY
INSURANCE INFORMATION
2014 575 Hill Country Dr. Ste 202 Kerrville, TX 78028 (830)258-6237 Office (830)315-1366 Fax Patient Name (last, first, MI) of Birth Social Security Number Mailing Address Home Telephone Work Telephone