Healthcare Gastroenterology Form

HEALTHCARE GASTROENTEROLOGY FORM

Patient Information

Date of Birth:

Gender: Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Presenting Complaint & Symptoms

Symptom Onset Date:   Duration (approx):

Pain Scale (0 = none, 10 = worst):

Medical History

Review of Systems — Gastrointestinal

Nausea/Vomiting    Blood in stool / hematochezia    Unintentional weight loss

Abdominal pain    Heartburn / reflux    Difficulty swallowing

Change in bowel habits    Fever/Chills

Prior Diagnostic Procedures

Prior Upper Endoscopy (EGD): Date:

Prior Colonoscopy: Date:

Procedure / Treatment Consent

Procedure to be performed (indicate planned procedure and any alternatives):

I acknowledge that the physician has explained the nature of the proposed procedure, expected benefits, material risks, and reasonable alternatives. I understand that potential complications may include, but are not limited to:

Bleeding    Perforation    Infection    Anesthesia/sedation related risks

I understand the alternatives to the proposed procedure, including observation, medical therapy, or alternative diagnostic testing, and I have had an opportunity to ask questions.

I consent to the administration of sedation/anesthesia as clinically necessary. I acknowledge that no guarantee has been made regarding the outcome of the procedure.

Please indicate acknowledgement of the following (initial/check as applicable):

I acknowledge the risks, benefits, and alternatives to the procedure.
I consent to sedation/anesthesia as needed.
My questions have been answered to my satisfaction.

HIPAA Authorization & Release of Information

I authorize the release of my medical information, including diagnostic and procedure reports, to the following individuals or entities for purposes of treatment, payment, and health care operations. I understand that this authorization includes information related to gastrointestinal conditions and procedures.

This authorization will expire on:

I understand that I may revoke this authorization at any time by providing written notice, except to the extent that action has already been taken in reliance on this authorization.

Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge, that I consent to the described evaluation and treatment, and that I authorize release of medical records as indicated above for treatment, payment, and health care operations.

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