Patient Information History Form

Personal Information

Maritial status

Last Name

First Name

Initial

Birthdate

Sex

Street Address

Apt#

City

State

Zip

Home Phone

Cell #

Work Phone

I prefer you leave a message about my treatment on my Home Work Cell

Email Address

Employer's Name

Employer's Address

Employers Phone

Your Occupation

Spouse's Information

Last Name

First Name

Initial

Birthdate

Patient's Insurance Information

Self Pay (no Insurance) Yes No

Primary Insurance Company Name

Policyholder Name

Policyholder Birthdate

Billing Address

Apt#

City

State

Zip

Relationship to Patient

ID#

Group #

Secondary Insurance Company Name

Billing Address

Apt#

City

State

Zip

Policyholder Name

Policyholder Birthdate

Relationship to Patient

ID#

Group#

Patient's Referral Information

Primary Care Dr. / Referring Doctor

Address

Phone

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Emergency Contact

Name of person NOT living with you

Relationship

Street Address

Apt#

City

State

Zip Code

Home Phone

Work or Cell#

Should inaccurate or omitted insurance information be supplied causing a reduction or non-payment of benefits, the obligation of payment will be transferred to the responsible party. I hereby authorize the release of any medical information necessary for the processing of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Peninsula GI. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment, or an electronic copy, is to be considered as valid as an original.

I Agree

I understand that I am providing my consent via e-signature by typing my name and clicking submit.

Signature / E-Signature

Date

IP Address

Atherton Endoscopy Center

Map & Directions

While you are a patient at Atherton Endoscopy Center, our highly competent and professional staff will care for you. Everyone from the receptionist to the physician embraces our philosophy of patient-focused care. Above all, our staff is friendly and concerned for your comfort.