This letter is to confirm your appointment on at with.
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- Merryl Osborne
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1 GATEWA GASTROETEROLOG IC. This letter is to confirm your appointment on at with. Our office is now using an electronic medical record. It is necessary to have your paperwork prior to your appointment. This paperwork is required for all patients regardless if you are already a patient with our practice. This new system requires that all data be entered on every patient. Please fill out the enclosed pre-registration forms and mail or fax it back to our office at prior to your appointment. If you fax your information, please bring the original documents with you. ou will also need to bring your insurance card(s) and a photo id so our office can have a copy for our records. IF you have an insurance plan that requires referrals to see a specialist, please contact your primary care physician and ask that they request a referral authorization number from your insurance. Currently, some of the required paperwork can be filled out on our Patient Portal. ou can access the Patient Portal once we have obtained your address. There is more information about our Patient Portal in this packet. The doctors office is located in St. Luke s Outpatient Center At 121 St. Luke s Center Drive, Building A, Suite 406, Chesterfield, MO It is on the west side of Highway 141/Woods Mill Road across from St. Luke s Hospital. Please help us out. If you are unable to keep your appointment, let us know AS SOO AS POSSIBLE at least 48 hours ahead of time. Someone else will want to use this time. If you have any questions regarding your visit, please feel free to contact our office.
2 GATEWA GASTROETEROLOG IC. WELCOME Dear Patient: Welcome to Gateway Gastroenterology! We look forward to meeting you. We d like to take this opportunity to tell you a little about our practice. Gateway Gastroenterology is a group of eight board-certified gastroenterologists that was established in Our areas of expertise include the esophagus, stomach, small intestine, colon, liver, gallbladder, and pancreas. We offer a wide variety of gastroenterology services including inpatient and outpatient consultation as well as a broad range of endoscopic procedures including screening colonoscopy, upper endoscopy, testing for dietary intolerance, etc. Our goal is to provide outstanding care in a timely, courteous, and professional manner. All of our physicians are committed to ongoing education and will make every effort to provide you with the most up to date and thorough care possible. We will try hard to make your experience with us as hassle-free as possible. To this end, we will see you in a timely manner, return phone calls, and communicate with your other physicians. Our practice includes Board Certified urse Practitioners who are specialized in gastroenterology and assist us in seeing patients in the office. Through their work, we are able to provide greater office time availability and flexibility. Our staff consists of friendly and knowledgeable people that are available to help with your scheduling, billing, and insurance needs. We look forward to working with you. Respectfully, David Benage, M.D. Jeffrey E. Matthews, M.D. Andrew. Su, M.D. Jeffrey T. Kreikemeier, M.D. Brian C. McMorrow, M.D. Fred H. Williams, M.D. Richard T. Riegel, M.D. Jonathan C. Seccombe, M.D. Cheri M. Carmody, A..P. Kaitlin C. Doneff, A.G..P. Dianna J. Gaffner, A..P.
3 GATEWA GASTROETEROLOG IC. PATIET PORTAL Gateway Gastroenterology has a Patient Portal for you to access some of your information. This portal shows any upcoming or previous appointments, some questionnaires for you to fill out prior to your appointments and you can also securely communicate with our office for questions to the doctor, nurse practitioner or staff. ou will get access to the Patient Portal once we have obtained your address and have entered it into our practice management system. ou will receive an once we have enabled you to continue the registration process. The web address: Please bookmark or save this to your Favorites. Questionnaires There are some questionnaires on this portal you can fill out instead of doing them in the paperwork we have sent you. At this time the portal does not show your medications or any results.
4 GATEWA GASTROETEROLOG IC. HOW DID OU HEAR ABOUT OUR PRACTICE? Primary Care M.D. OB/G Internet Friend/Family Advertisement Other ame: Sex: Male / Female Date of Birth: Address: City: State: Zip Code: Social Security umber: Home Phone umber: Employer: Marital Status: Address: Alt. Contact umber: Occupation: Spouse s ame: Emergency Contact: : Phone umber: Primary Care Physician: Referring Physician: The following is required by the State of Missouri (select one): Hispanic or Latino either Hispanic nor Latino RACE White Black or African American American Indian Alaska ative Asian ative Hawaiian/Pacific Island Other not listed Multi-Racial (two or more races) Choose not to answer Language Spoken: MEDICAL ISURACE IFORMATIO Primary Insurance Company: Policy/Id umber: to policy holder: Secondary Insurance Company: Policy/Id umber: to policy holder: Phone umber: Group umber: Policy Holder DOB: Phone umber: Group umber: Policy Holder DOB: POLIC HOLDER IFORMATIO (IF OTHER THA PATIET) ame: Mr/Mrs/Ms. Address: City: State: Zip Code: Date of Birth: Home Phone umber: Employer: to Patient: Alt. Contact umber: Occupation: Responsible party/guarantor s Signature: RELEASE OF IFORMATIO/ASSIGMET OF BEEFITS/RECEIPT OF PRIVAC PRACTICES POLIC By providing the information I agree that Gateway Gastroenterology, Inc. or one of its legal agents may use the telephone numbers provided to send me a text notification, call using a pre-recorded/artificial voice message through the use of an automated dialing service, leave a voice message on an answering device, send mail to my home address, or notification regarding my care, our services, or my financial obligation. I hereby authorize the release of any medical information necessary to process my health insurance claims. I permit a copy of this authorization to be in place of the original. I have received a copy of otice of Privacy Practices. Signature Date
5 GATEWA GASTROETEROLOG IC. MEDICATIO RECOCILIATIO FORM For Medical Records purposes, we will need you to provide us with a list of your current medications. This information is very important to us. Please complete this list below. Thank ou! Patient ame: Date: Date: MEDICATIO ALLERGIES AD REACTIOS Check if o Known Drug Allergies MEDICATIO LIST Medication ame (Prescription Medications) Dosage Frequency (How Often) Reason for Use List name(s) of any Over the Counter Medications/Herbal Supplements PHARMAC AME Local: Mail Order: Phone umber: Phone umber:
6 GATEWA GASTROETEROLOG IC. SMPTOMS Patient ame: Date of Birth: Date: Constitutional Symptoms Fever Chills Recent Weight Change Integumentary (Skin) Rash Itching Change in skin color Reaction to sunlight Eye/Ears/ose/Mouth/Throat Blurred or double vision Visual loss Ringing of the ears Dizziness Hearing loss eurological Stroke Convulsions or seizures Tremors Paralysis Genitourinary Burning or painful urination Frequent urination Incontinence or dribbling Renal failure Blood in urine Musculoskeletal Joint pain Joint stiffness or swelling Weakness of muscles Hematologic/Lymphatic Endocrine Bleeding or bruising tendency Hemophilia Blood cancer Swollen lymph nodes Anemia Thyroid disease Diabetes Excessive thirst/appetite Psychiatric Cardiovascular Delusions Hallucinations Palpitation Loss of consciousness Heart trouble Shortness of breath with walking/lying flat Chest pain or angina pectoris Suicidal thoughts Allergic/Immunologic Hives Chronic sinusitis History of anaphylaxis Respiratory Chronic or frequent cough Spitting up blood Asthma or wheezing Tuberculosis Shortness of breath Reviewed By:, MD Date:
7 GATEWA GASTROETEROLOG IC. PATIET HISTOR FORM Patient ame: Date of Birth: PERSOAL MEDICAL HISTOR: GERD Celiac Sprue Heart Disease/ Stents COPD Barrett s Esophagus Pancreatitis CHF Anemia Schatzki s Ring Liver Disease High Blood Pressure Seizures Hiatal Hernia Colon Polyps/Colon Cancer Stroke Migraines Esophageal Cancer Diverticulosis/Diverticulitis Diabetes Sleep Apnea Stomach Cancer Crohn s Kidney Problems Hearing Loss Ulcers Ulcerative Colitis Asthma Cancer SURGERIES HOSPITALIZATIOS OTHER THA SURGERIES LAST COLOOSCOP LAST UPPER EDOSCOP SMOKIG ALCOHOL ear: ear: es es o o FAMIL HISTOR OF COLO CACER? FAMIL HISTOR OF POLPS? Pk/rs: Drinks/day: es o If yes, who? es o If yes, who? r Quit: r Quit: Patient s Signature Date urse s Signature Date
8 GATEWA GASTROETEROLOG IC. IFORMATIO RELEASE I (Print Patient s ame Here) give consent for any medical information to be released to the following parties: IFORMATIO TO BE RELEASED TO THE FOLLOWIG PARTIES: It is the patient s responsibility to contact this office if any name listed above would need to be removed. A new consent form would need to be filled out. Patient Signature Date of Birth Date Witness
ENDOSCOPY PREPARATION INSTRUCTIONS
GATEWAY GASTROENTEROLOGY INC ENDOSCOPY PREPARATION INSTRUCTIONS Your procedure is scheduled for at Gateway Endoscopy Center 12855 North Forty Drive South Tower, Suite 150 St. Louis, MO 63141 (314) 336-1130
DENTON UROLOGY 2401 West Oak Street Ste. #102 Denton, Texas Phone: Fax:
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PLEASE FILL OUT FORM BELOW AND THEN FAX BACK TO: ADDITIONALLY, PLEASE BRING FORM WITH YOU ON THE DAY OF YOUR SCHEDULED APPOINTMENT.
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GATEWAY GASTROENTEROLOGY INC COLONOSCOPY PREPARATION INSTRUCTIONS Your procedure is scheduled for at Gateway Endoscopy Center 12855 North Forty Drive South Tower, Suite 150 St. Louis, MO 63141 (314) 336-1130
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Name (Last, First, MI) Faculty Group Practice Patient Demographic Form Email address Patient Information Street Address City State Zip Home Phone SSN Date of Birth Gender Male Female Work Phone Cell Phone
Tennessee Neurology Specialists Affiliated with Baptist Healthcare Group
Tennessee Neurology Specialists Affiliated with Baptist Healthcare Group Oscar E. Mendez, M.D. Rejane Lisboa, M.D. Williamson Medical Center Tower 4323 Carothers Pkwy, Suite 303 Franklin, TN 37067 Phone:
Dear, Thank you for trusting your care to Comprehensive Breast Care Surgeons. Your appointment is with at our. office. It is scheduled on at
Beth DuPree MD, FACS, ABIHM Stacy Krisher MD, FACS, ABIHM Catherine Carruthers MD, FACS, ABIHM Amanda Woodworth, MD 45 2nd Street Pike Suite 100 Southampton, PA 18966 Dear, Thank you for trusting your
PATIENT DATA, PAGE 1 FORM MUST BE COMPLETED IN FULL (Please Print)
PATIENT DATA, PAGE 1 FORM MUST BE COMPLETED IN FULL (Please Print) Name Today's Date Social Security No. Date of Birth Marital Status Married Single Widowed Divorced Gender Male Female Home Address Phone
Age: Birthdate: Date of Last Physical exam:
Name: : Age: Birthdate: of Last Physical exam: SYMPTOMS: Check symptoms you currently have OR have had within the past YEAR. General Fever Chills Weight loss Weight Gain Headache Depression Vertigo Ringing
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
Patient Last Name: First: MI:
California NeuroInstitute, Inc. Work Comp, Auto Accident or Personal Injury (All Information MUST be completed in order to bill your insurance company) Patient Last Name: First: MI: Date of Birth: Age:
TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP DATE OF BIRTH
TODAYS DATE WHICH PHYSICIAN ARE YOU SEEING TODAY? NAME (LAST) (FIRST) (MI) ADDRESS CITY STATE ZIP HOME PHONE CELL PHONE WORK PHONE MALE FEMALE DATE OF BIRTH EMAIL SOCIAL SECURITY # DRIVERS LICENSE # DRIVERS
If you have health insurance, please bring your insurance card(s) so that we may verify eligibility and bill correctly.
Vimali Paul, MD David Alonso, MD Laura Loudermilk, FNP Joy Culp, FNP 85 Declaration Dr., Ste. 110 Chico, CA 95973 (530) 894-6600 phone (530) 894-1321 fax Dear Patient: Welcome to the practice! The forms
Thank you for contacting the Saint Francis Center for Surgical Weight Loss.
Saint Francis Center for Surgical Weight Loss 6005 Park Avenue Ste. 1011B, Memphis Tn. 38119 ***PLEASE NOTE This is our office, not our seminar address. Please see directions to our seminar location at
Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W
Date: Sex: M or F Patient Name: First Middle Last Address: City: State: Zip Code: Date of Birth: Social Security: Marital Status: S M D W Home Phone: Work Phone: Cell Phone: Email Address: Employment Status:
Integrative Therapies 7E Oak Branch Drive Greensboro, NC
Integrative Therapies 7E Oak Branch Drive Greensboro, NC 27407 www.integrativetherapies.net 336-294-0910 Hello! Welcome to Integrative Therapies and Integrative Pain Medicine, We are very happy that you
NEW PATIENT WELCOME LETTER
NEW PATIENT WELCOME LETTER We respect your time: In order for you (and the other patients on the schedule) to be seen with minimal wait, patient registration and paperwork must be completed BEFORE your
CENTER FOR DIGESTIVE HEALTH
Dear Patient, Welcome to our practice. Attached are forms which will provide us with your detailed information for your appointment. Thank you in advance for your cooperation in form completion. We look
Please complete all pages of this form. Your physician will review the form with you during your appointment. Last Name: First Name: Middle Initial:
Please complete all pages of this form. Your physician will review the form with you during your appointment. Patient Information Last Name: First Name: Middle Initial: Date of Birth: / / Age: SSN: - -
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet
SoutheastHEALTH Occupation Medicine Clinic Patient Information Sheet DATE Name (First, Middle, Last): Date of Birth: SSN: Mailing Address: City, State and Zip: Phone: Home Cell Other Alt Phone: Home Cell
Patient Day of Surgery Package of Forms. Includes: Patient Rights & Responsibilities. Statement of Limitation Regarding Advance Directives
Patient Day of Surgery Package of Forms Includes: Patient Rights & Responsibilities Statement of Limitation Regarding Advance Directives Patient Medication History Acknowledgement of Requirement for Responsible
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c
W e l c o m e t o B i l l e r i c a C h i r o p r a c t i c N E W P A T I E N T I N T A K E F O R M Print Name Today s Date Address City State Zip Email Address Date of Birth Male Female Social Security
Adult Health History
Adult Health History Name: DOB: Please list medications, including: vitamins, herbs, homeopathic remedies, and nonprescription medicines on the attached medication sheet. Medical History: High blood pressure
Patient Registration PATIENT INFORMATION - the person being seen by the doctor
Patient Registration PATIENT INFORMATION - the person being seen by the doctor Last Name First Initial Home Address Zip City State Mailing address Zip City State Email I am willing to receive emails from
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip
PATIENT INFORMATION Name: Date of Birth Address: City: State: Zip Primary Phone ( ) Secondary Phone ( ) Other Phone ( ) SS# - - Race Ethnicity Email address Preferred language Marital Status Minor Single