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Patient Name:

F-t_ot=tc).A.

Patient Registration Form

Preferred Iirst

E Male lFemale SSN:

State: zip:

Cell#:

DOB:

PrimaryAddress:

City:

Phone#;

Secondary Address

City: State: zip:

Alternate Phone#: Type tHome n Cell trWork

Ethnicity: trHispanic or Latino nNot Hispanic or Latino trOther !Declined

Nationality: EAmerican lndian or Alaska Native trAsian EBlack or African American

trNative Hawaiian or Other Pacific lslander tr White DOther trDeclined

Primary Language:

Preferred method(s) of contact: trMail trEmail IHome Phone ECell Phone DText trOnline Portal

Personal Emai t:

Pharmacy Name/Location Pharmacy Phone:

Primary Care

Whom may we thank for referring

Employer Status: trEmployed DSelf-Employed ERetired CDisabled EUnemployed DStudent

Employer Address Work Phone:

EMERGENCY CONTACTS

#1. Name:

#2. Name:

Relationship:

Relationship:

Phone#:

Phone#:

INSURANCE INFORMATION

Primary lnsurance Carrier: Eligibilty Phone#:

Policy holder lD: Group tn

Policyholder's Name: Date of Birth Sex: E Male EFemale

Policyholder's SS#: Relationship to patient:

Secondary lnsurance Carrier: Eligibilty Phone#:

Policy holder lD: ID:

Policyholder's Name: Date of Birth_ Sex: tr Male EFemal€

Policyholder's SS#:: Relationship to patient:

PLEASE COMPLETE ALL PAGESAND BRING THE FORMS WITHYOU TO YOUR APPOINTMENT

PLEASE DO NOT MAIL

Please Print

Gulfcoost Gostroenterology ConsultontsDiplomates American Board of Castroenterology and tnternal Medicine

HEALTH QUESTIONNAIRENAME DATE

ADDRESS

Personal Physician

Refening Physician

Address

Address

PLEASE LISTYOUB CURBENT SYMPTOMS AND MEDICAL PROBLEMS:

2.

3.

Please Circle One: Hispanic / Non-Hispanic

Please Circle One: Everyday Smoker Some-day Smoker

Former Smoker Never Smoker

HAVEYOU EVEB HAD:

HEG. T/EASLES NO

NO

NO

YES

YE5

YES

WHOOPING COUGH NO YES

SMALL POX

TYPHOID FEVEFI

TUBERCULOSIS NO YES

STREP THROAT NO YES

GER. MEASLES NO YES

DIPHTHERIA NO YES

SYPHILIS NO YES

INFLUENZA NO YES

SCARLET FEVER NO YES

POLIO NO YES

[/UMPS NO YES

CHICKEN POX NO YES

GONORRHEA NO YES

PNEUMONIA NO

NO YES

YES

RHEUMATIC FEVER NO YES

[/ENINGITIS

PLEASE LIST ALL OFYOUR HOSPITALIZATIONS IN CHFONOLOGICAL OBDEB:DATE HOSPITAL PRoBLEM OATE HOSPITAL PBOBLEM

4.

5.

6.

2.

PLEASE Llsr ANY orHER sEBtous MEDtcAL coNDtTloNS oR TLLNESSES: ANy INJURtES:

2.

3.

4.

'1.

2.

J.

4.

MEDICATIONS: LIST ALL MEDICATIONS YOU ARE CUBBENTLY TAKING:

6.

7.

2.

3.

4.

ALLEBGIES:

PENICILLIN

SULFA DHUGS

BARBITUFIATES

EGGS

NO

NO

NO

NO

NO

NO

NO

YES

YES

YES

YES

LATEX

IV DYE

SHELL FISH

YES

YES

YES

PEBSONAL HISTOBY:

PLACE OF BIRTH

-

SIATES IN WHICH YOU HAVE LIVED

COUNTRIES WHEREYOU LIVED OR VISITED

CUBRENT OCCUPATION

PREVIOUS OCCUPATION

ALCOHOL CONSUI\,1PTlON

TYPE- OUANT. PER WEEK

COFFEE, CUPS PEH DAY

-

TEA. CUPS PEB DAY

BEGULAR EXERCISE trYES T NO TYPE

POS'Beorder # 1 1C5223

NAME DATE

FAMILYHISTORY

FATHER

MOTHER

!BROTHEB NSISTER

tr BROTHER T SISTER

- BROTHER D SISTER

trBROTHER trSISTER

D BROTHER tr SISTER

HUSBAND OR WIFE

I SON tr DAUGHTER

tr SON N DAUGHTEB

N SON N DAUGHTER

N SON fI DAUGHTER

SYSTEMS REVIEW: Have you had any of the lollowing problems within the past 3 months?

RECORD THE APPROXIMATE DATE YOULAST HAD ANY OFTHE FOLLOWING:

COMPLETE IMEDICAL EXAIVI trY NN

WOMEN - PAP SMEAR trY trN

CHEST X-RAY NY NN

TEST STOOL FOB BLOOD trY trN

PROCTO L-Y !N

EKG DY fNHEPATITIS SCBEENING frY !N

DATE HAD

YES

YES

YES

YES

H. FREQUENT HEADACHES............ NO

IVlIGBAINE HEADACHES.-..-.-....,-. NO

LOSS OI: SME1L.... .................

FREOUE NT COLDS................ ..

POST NASAL DBtp ................. .

T. FREOUENT SORE THROAT......, . NO

CHRON1IC HOARSENESS.... ......, NO

sTREP TH ROAT............................ NO

PULM. cHRONTC COUGH........................ NO

couGHrNG 81OOD..................... NO

SPUTUIV PRODUCTION .,...-........ NO

SHORTNESS OF BREATH........... NO

ASTHI\,,IA,.,.... NO

CV. CHEST PAIN...... NO

HEART ATTACK ............................ NOPALPTTATTONS . ............................ NO

CALF PAIN ......... NO

HEART tMUHTVUR ......................... NO

HIGH BLOOD PRESSURE.,,........ NO

LOW BLOOD PRESSUFE............ NOFATNTtNG Sp81LS........................ NO

GI. PEPTIC ULCEB DISEASE....,....,,. NO

RECUR. ABDOMINAL PAIN,,,,..,..- NO

BLACK OR BLOODY STOOLS..,,. NO

E. EARINFECTtON........................... NO yES

RtNGtNGtNEARS........................ NO yES

N. NOSE 81EEDS............................. NO YES

YES

YES

YES

YES

DISCHAI]GE

voMrTtNG 81OOD....................... NO

votv lTt NG ..................................... NO

CHANGE IN BOWEL HABITS......, NO

CHANGE IN STOOL APPEAR..,,.. NO

coN sTr PATroN............................. NO

D1AF8HEA.................................... NO

INTEST. PARASITES (worms)....... NO

DIFFICULTY SWALLOWING....,.... NO

FREQUENT HEART BURN...,...,... NO

HIATUS (HTATAL) HEFNtA........... NO

GALLSTON ES............................... NO

HEPATtTtS.............. NO

JAUNDICE (Yel. Jaundice)............. NO

ctRRHOSTS OF 1tVER....... ......... NO

N.P. STROKE.. ........... NO

PARALYSIS OB WEAKNESS..., ,.. NO

LOSS OF SENSATrON.......... . ...

SPEECH ABNORIi/A11TY ..........

CONVULSION...

LOSS OF BALANCE

DEPRESSION...

CONFUSION

CFYING SPELLS

MS JOrNTPAtNS......................... ..... NO

TENDER, SWOLLEN, RED OB HOT

JOrNTS......................... ............... NO

BACK PAtN................ ................... NO

FREQUENT LEG CRAN/PS...,...... NO

HEM

oNc. LOSS OF APPETtTE.............. ...... NO

UNEXPLAINED WT, LOSS.,........,. NO

ANY LUI\4P OR N4ASS................... NO

REMOVED................. ........WHEN

UNUSUAL N/OLE OR WART......... NO

ENLAFGED LYIUPH NODES......-. NO

ANEtVtA............. . ........... NO yES

TREATMENT..... DATE................

BLOOD TRANSFUSION ....,.......... NO YES

wHEN................WHy............. # UNtTS... ......

EXCESSIVEBLEEDING....,..,....... NO YES

RECUHRENT NOSE BLEEDS.,.... NO YES

EASY BRUISA8ILITY,........,,..,....., NO YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

YES

YES

YES

YES

YESYES

Yt5YES

YES

YES

YES

YES

YES

MALE ONLY

PROSTATE TROU81E,.,....,.......... NO

DIF. INITIATING STREAIM ...,..,,..... NO

INTERBUPTED STREAIvI ............. NO

II\4POTENCE

FEMALE ONLY

DATE OF LAST PERIOD,..

DURATI ON OF pEF tOD.......................... DAYS

LENGTH OF CyCLE...... .... ................... DAYS

NO, OF PBEGNANCIES

EX, FLOW DURING PERIODS..... NO YES

BLEED, BETWEEN PERIODS.,,.., NO YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

NO

NO

YES

YES

YES

YE5

YES

YES

YES

YES

YES

YES

YES

YES

YES

AGEIF LIVING,HEALTH

IF DECEASED,CAUSE

\GE ATDEATH

1

2.

o,

4.

5.

1

2.

3.

4.

KIDNEY/BLADDEB INFEC..,,..,..,.. NO

PAIN OR BURN. URINATION,,.,,.., NO

PUS tN URtNE.............................. NO

BLOOD tN URrNE................ ... .. NO

URINARY FREOUENCY..,....,..,.... NO

URtNARY URGENCy.................... NO

URINATING AFTEB BEDTIME,..... NO

URINARY DRIB8I1ING..,.....,....,... NO

KIDNEY/BLADDER STONES,...,... NO

YES

YES

YES

YES

YES

YES

YES

YES

YES

G.U.

ENDO. FECENT WT. GAIN ..,......,,,..,,....... NO

EXCESSIVE SWEATING.........,,.,,. NO

DIABETES (sugar in urine)............ NO

HIGH CHOLESTERO1..,....,..,,...,,. NO

YES

YES

YES

YES

NERVOUS BFEAKDOWN.....,..,,,,. SIGNATUREPOS Beorder # 121 8404

G"a\.STFt_ORI DA

Patient Consent

Request for Care and Consent for Treatment

The undersigned consents to the medical care and treatment, as may be deemed necessary or advisable in the judgmentof my physician or other provider, which may include but are not li-;b4 to laboratory piocedures, X-ray examina[ion,medical or surgical treatment orprocedures or other services rendered to the patient ooa"r the general and specialinstructions of the patient's physician. Gastro Florida has the right to refuse io treat you if yorireftrse to sign ttrisconsent or rf, at any time, you choose to revoke this consenl

Assignment of Insurance Benefits

I authorize payment directly to Gastro Florida of any insurance benefits otherwise payable to me for services, at a rutenot to exceed Gastro Florida regular charges for such services.

Authorization to Release fnformation

I authorize the release of medical records and related information from Gastro Florida to authorized representatives ofmy third prty payor or physician related to my care. I authorize review of records for any necessary agency audit andthe release of the physician plan of care and discharge summary from my medical record Lprn -y tianifer io or fromanother health care facility

Permission for Treatment

Permission is hereby granted for physicians and employees or agents of the Practice to render the patient named belowsuch medical and surgical treatment as is deemed necessary.

The undersigned certifies that helshe has read the forgoing, received a copy therof and is the patient or is dulyauthorized by the patient as patient's general agent to execute the above and accepts its terms.

Patient/ Guardian Signature Date

Printed Name of Person Signing Consent Forrn

If other than the patient (Parient Name)_ is signing, are you the legal guardian, custodianor have Power of Attorney for this patient, for treatment, payment or healthcare operations? E Yes tr No

STT<O

Waiver of "Usual, Customary and Reasonable" Clause s (For patients with "Out-of-Network" coverage)I acknowledge that the fee charged by the Practice for services rendered to me, or to the person for whim I assume financial responsibility,may exceed the fee considered 'usual, customary and reasonable", due to specialized services and staff. However, I agree to pay thePractice fees in full, even if the arnount is greater than what I am reimbursed from my insurance company.

/F r_aF?tDA.

OUR FINANCIAL POLICY

IL.$ {qy lol. choosing.us as y-our health care provider. We are committedto the success of your treatment. Please understand that paymerof your bill is considered part of your treatment arangement. The following is a statement of our Financial Policy, which we require you t6 rea,prior to any treatment.

All patients must complete our Flegistration and History forms before seeing the doctor. You must supply us with both your insurance card antdriver's license prior to your visit.

FULL PAYMENT tS DUE AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, or VISA/MASTERCARD/D;SCOVER.

Statement of Financial ResponsibilityI understand that I am responsible for the payment of this account, and hereby assume and guarantee prompt payment of all the expensesincured.

Notice of "Non-Covered" ServicesI am aware that sorne services performedwill become fully responsible for payrnent

bythe practice may be considered 'non-covered" by my insurance carrier or Medicare, therefore Iof these services.

Bill To/PJyment lnstructions

_ Commerciallnsuranceffhird Party Payor _ Medicare "Medigaptnitiat tnitiat lnitiat

I hereby authorize the Practice to bill my insurance company andlor Medicare (indicated or initialed above) for services provided to me andrequest that payment for such services be made to the Practice on my behalf.

*lf Medigap .-@Medigap Policy Number

List Names of Those Whqm You Want Us to Share Your Financial Responsibillty tnformatton:

Name: Relationship:

Financial AgreementThe undersigned agrees, whether helshe signs.as agent or as patient, that in consideration of the service to be rendered to the patient, helsheobligates himself/herself to pay the account of the Practice in accordance with the regular rates and terms of the Practice. Should the accountbe referred to an outside agency or an attorney for collections, the undersigned agrees to pay reasonable collection and attorney tees torcollection expenses.

Billing QuestionsPlease address all billing questions to our central Business oflice (727) 347-0005.

Payment PlansYou can call our Central Business Office to determine if you qualify for this arrangement.

Patient Name:(please print)

Patient (or legal guardian's)

Date

Witness Date

H

STf<OFI-ORID.A.

HIPAA Consent

I understand that as part of my healthcare, the practice originates and maintains paper and /or electronic recordsdescribing my health history, symptoms, exemination and test results, diagnoses, fteatment, and any plans for fufuretreatment. I understand that this information serves as:

. A basis forplanning my care and treatmento A means for communication among health professionals who contribute to my care, such as referralsr A source of infor:nation for applying my diagnosis and treatment information to my billr A means by which a third-parrypayer can verify that services billed were actually renderedr I tool for routine healthcare operations, such as assessing qualiry and reviewing the competence of staff

I have been provided with a"Notice of Patient Privacy Practices" thatprovides a more complete description ofi::formation uses and disclosures. I understand that I have the following and privileges:

o The right to review the "Notice' prior to acknowledging this consenco

_The right to restrict orrevoke the use or disclosure of my health information for other uses orpurposesr The right to request restrictions as to how my health information may be used or disclosed to carry out

treatment, payment, of healthcare operations.

Please PrintRestrictionsI request the following restrictions to the use or disclosure of my health information:

Please telI us with whom we may discuss yourprotected health inforrnation:@xample: spouse (name), children (name(s)), other relatives (name(s), friends or caregivers (name(s))

Messages or Appointment RemindersMay we leave a message at your home using doctor's lpracttce name:

May we leave a message at your work using doctor's lpracttce name:

E Yes

E Yes

trNotrNo

I understand that as paft of treatment, paynxent, or healthcare operations, it may become necessary to disclose healthinfonnation to another endry, i.e. referals to other healthcare providers. I consent to such disclosure for these uses as

permitted by law. I fully understand and fi accept ! decline the information of this consent.

Notice of Privacy Practices

f acknowledge that I have been provided with the Practices' Notice of Privacy Practices that provides a descriptionof Protected Health Information use and disclosures. I understand that I have the right to review the Notice of PrivacyPractices prior to siguing this statement. I understand that the Practice reseryes the right to change is Notice of PrivacyPractices that will be effective for health inforrnation the Practice akeady has about me, as well as any they receive inthe future. The Practice3 will post a current copy of the Notice. I understand that I may obtain a copy of the curentNotice in effect upon request. I have read all of the above and underst and/agree to all the provisions therein regardingresponsibility for payment, permission for treatment and Notice of Privacy Practices.

PatienU Guardian Signature Date

Printed Name of Person Signing Consent Form

If other than the patient (Patient is signing, are you the legal guardian, custodianor have Power of Attorney for this patient, for treatment, payment or healthcare operations? tr Yes ! No