200 Tamal Plaza, Suite 200,  Corte Madera,  CA  94925

PATIENT INFORMATION

Patient Name*
Address
Date of Birth*
Marital Status
Employment
Would you like information on advance directives?
Advance directives are legal documents that allow you to spell out your decisions about end-of-life care ahead of time. They give you a way to tell your wishes to family, friends, and health care professionals and to avoid confusion later on.
What is your preferred language?

The Centers for Medicaid Services request that we report the following information regarding Race & Ethnicity:

Race
Ethnicity
Preferred Pharmacy Address

Marin Gastroenterology offers a secure portal for patients. You will receive an invite to join our portal via the email address you provide. We encourage you to sign up and take advantage of accessing your physician via secure email, reviewing your medical record, and request appointments without having to pick up the phone

Emergency Contact

Emergency Contact

CURRENT MEDICAL INFORMATION

Patient Name - Copy*

Please list the additional doctors involved in your care.  We will send him/her your records from the office

PLEASE LIST ALL OF YOUR CURRENT MEDICATIONS AND/OR SUPPLEMENTS

What is the name of the medication or supplement
How often do you take this medication or supplement?

If you have a medication/allergy intolerance, please list the allergy and reaction below:

What are you allergic to?
What reaction do you experience when exposed?
What Condition(s) are you here to address? Please check box if applicable.

ANESTHESIA QUESTIONAIRE

Gastroenterology is a procedure based specialty. Should you need a procedure, these questions help ensure your safety and comfort.

Have you ever had a problem with sedation or anesthesia?*
Have you ever been diagnosed with breathing or lung problems? *
Please check the box(es) that best describe the breathing or lung problems you have been diagnosed with:
Do you use oxygen at home?*
Have you ever been diagnosed with a heart problem?*
Please check the box(es) that best describe the heart problem(s) you have been diagnosed with:
Have you ever had the following heart procedures:
Are you currently being seen by a cardiologist? *
What was the date of your last visit to your cardiologist
Additional Screening Questions
Additional Screening Questions
  Yes No N/A
Do you take ASPIRIN, ANTICOAGULANTS or "BLOOD THINNERS"? (Coumadin/warfarin, Xarelto/rivaroxaban, Eliquis/apixaban, Pradaxa/dabigatran, Savaysa/edoxaban, Effient/prasugrel, Aggrenox/dipyridamole, Plavix)
Do you have an allergy or sensitivity to LATEX?
Do you use INSULIN?
Are you currently or anticipating becoming PREGNANT?
Do you require HEMODIALYSIS for kidney disease?
Use your mouse or finger to draw your signature above

MEDICAL HISTORY

PLEASE CHECK ALL MEDICAL CONDITIONS THAT YOU ARE OR HAVE BEEN TREATED FOR
PLEASE CHECK ALL MEDICAL CONDITIONS THAT YOU ARE OR HAVE BEEN TREATED FOR
  Current Past
Stroke
Atrial Fibrillation
Asthma
Arthritis
Osteoporosis
Chronic Pain
High Cholesterol
Diabetes
High Blood Pressure
Hypo/Hyperthyroidism
Depression
Anxiety
HIV/AIDS
Tuberculosis
Migranes
Parkinson's
Multiple Sclerosis
Cirrhosis
Hepatitis A
Hepatitis B
Hepatitis C
Endomitrosis
Fibroids
Have you been diagnosed with Cancer?

REVIEW OF SYMPTOMS

Are you currently experiencing any of these symptoms?
Are you currently experiencing any of these symptoms?
  I am experiencing this symptom
Fever
Heavy menstrual bleeding
Recent involuntary weight loss
Skin rash
Decreased appetite
Itchy skin
Eye pain
Headaches
Red eye
Significant memory loss
Sore throat
Anxiety
Hoarse Voice
Depression
Chest Pain
Difficulty sleeping
Rapid irregular heart beat
Intolerance to heat
Intolerance to cold
Shortness of breath with exercise
Cough
Hair Loss
Blood in Urine
Seasonal Allergies (e.g. Hay Fever)
Flank pain
Fatigue
Allergies to contact with adhesive tape or latex

PAST SURGICAL HISTORY

Please Indicate the operations performed:

Colonoscopy*
Upper GI Endoscopy
Other GI Endoscopy (ERCP, EUS, Capsule Endoscopy)
Appendectomy (Removal Of Appendix)
Cholecystectomy (Removal Of Gall Bladder)
Fundoplication (Surgery For Acid Reflux)
Weight Loss Surgery
Hysterectomy (Removal Of Uterus)
Oophorectomy (Removal Of Ovaries)
Removal Of Part Of Colon
Any Other Abdominal Surgery
Habits
Habits
  Yes No
Do you use Tobacco?
Have you ever used Tobacco?
Do you use Marijuana?
On average, how much alcohol do you drink DAILY? Please select most accurate:

FAMILY HISTORY

Are you aware of the medical history of your family (parents, grandparents, aunts/uncles, siblings)
Do you have a parent or sibling who had COLON CANCER?
Do you have a parent or sibling who had UTERINE CANCER?
Do you have a grandparent, aunt or uncle who had COLON CANCER?
Do you have a parent or sibling who had COLON POLYPS?

RECENT WORK-UP

Have you had a BLOOD TEST in the last 3 months?
Where was the BLOOD TEST performed?
Have you had any IMAGING (CT, MRI, Ultrasound, X-Ray) performed in the last 3 months?
Where was the IMAGING performed?
Have you had a BONE DENSITY STUDY completed in the past 2 years?
Where was the BONE DENSITY STUDY performed? - Copy

VACCINATIONS

PATIENT ACKNOWLEDGEMENT

This section describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

*PLEASE PLACE A CHECK MARK indicating that you have read and understand each statement. If you wish to make changes to a section, please notify the receptionist so that your file is noted properly in our records. Please sign and date the bottom.

Check each box to indicate you have read and understand:*
*

Please note in order to avoid misuse of your protected medical records or information, it is our policy to release minimum amount necessary, even to those you have agreed may have access.

BENEFIT ASSIGNMENT & ACKNOWLEDGEMENT OF FINANCIAL RESPONSIBILITY:  I authorize my insurance company to make payment directly to Marin Gastroenterology and the Endoscopy Center of Marin on my claim for medical services provided to me or my dependents. I understand that I am financially responsible for payment of all non-covered services, co-pays, deductibles and any other charges my insurance company deems my responsibility.  

RELEASE OF RECORDS:   I hereby authorize the release of information, verbal and written, contained in my medical record to my insurance company and related healthcare providers only as it relates to my treatment. In addition, I hereby authorize Marin Gastroenterology and the Endoscopy Center of Marin to obtain medical records and/or professional information from my physician or other medical professional only as it relates to my treatment.

Use your mouse or finger to draw your signature above

Please be advised that by completing this preliminary health and insurance questionnaire, it does not establish a physician-patient relationship with this practice

FINANCIAL RESPONSIBILITY

You are responsible for all costs of your treatment. Your insurance may or may not cover all of the costs associated with the plan of care pursued by you and your physician. All copays are due at the time of service. As a courtesy to you we will bill and collect the amounts allowed by your insurance contract for your treatment. We advise that you make sure of your insurance benefits before undergoing treatments / procedures. 


ADDITIONAL FEES DISCLOSURE Please be aware that certain services are not typically covered under the scope of a routine office visit by your insurance and, as such, are billed directly to you as follows:

Forms / Letters requiring completion by the MD (This includes state, commercial disability, work,jury,travel excuses, DMV forms etc)
$35.00 per page
New Patient Office Visit “No Shows” or Cancellation less than 24 hrs. (payable before rescheduling)
$100.00 each time
Established Patient Office Visit “No Show” or Cancellation less than 24 hrs. (payable before rescheduling)
$50.00 each time
Procedure Cancellations with less than 7 days’ notice (payable before rescheduling)
$150.00 each time
Returned Check / NSF Fee
$40.00 per incident


The following services will be billed to your insurance as permitted:

  • Patient initiated telephone Consultation/ Return Call
  • Care Coordination with other Providers


LATE ARRIVAL POLICY 

Please be aware that if you are late to your appointment you may be asked to reschedule your visit or may have to wait until we can fit you in after our on-time arrivals have been seen. 


CODE OF CONDUCT 

Marin Gastroenterology asks that patients be responsible participants in their care. Our expectation of responsible participation includes keeping your appointments and arriving on time, being considerate towards your provider, their staff members and other patients. We do not condone the use of profanity or arriving under the influence of alcohol or drugs. Patients who choose not to abide by this code of conduct, will be terminated from the practice. If you are requiring a medication refill and have not been seen by the prescribing MD here at the practice in over 6 months you will be required to make an office visit prior to your prescription being renewed.

Use your mouse or finger to draw your signature above

WHERE ARE YOU COMPLETING THIS PATIENT FORM?

Where are you completing this Patient Form

As you are completing this Patient form outside of the Doctor's Offices, we need you to provide some additional data:

Progress
Powered by Formstack Create your own form ›
Cancel
Confirm