This letter is to confirm your appointment on at with.

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GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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 314-275-3704 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 email 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 63017. 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.

GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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 1984. 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.

GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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 email address and have entered it into our practice management system. ou will receive an email once we have enabled you to continue the registration process. The web address: https://health.healow.com/gatewaygi 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.

GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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: Email 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 email 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

GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. List name(s) of any Over the Counter Medications/Herbal Supplements 1. 2. 3. PHARMAC AME Local: Mail Order: Phone umber: Phone umber:

GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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:

GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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

GATEWA GASTROETEROLOG IC. WWW.GATEWAGI.COM 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

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