California Advanced Gastroenterology

"Our bowels are at their best when they function silently and with only intermittent recognition.” 
Sherwood Gorbach, 1974

Easy Access Colonoscopy
    Patient Registration

 

  Name          
                                        first                     mi                       last

  Address:    

  Address2   

  City                   

  State                   

  Zip Code     

  Telephone   home     work

  Email              

  Date of Birth      Age     
                                            mm/dd/yy                 

  Social Security #      

  Employer                     
 

  Spouse's Name                    
                                                               first                     mi                       last    
  Spouse's Soc Sec #          

  Spouse's Employer            

 

  Primary Care Physician    

  Emergency Contact  name        

                                    telephone


  Insurance Information
 

  Primary Insurance Company 

  ID or Policy #

  Group #          

  Insured's Name  (if different)    

 

  Secondary Insurance Company

  ID or Policy #

  Group #          

  Insured's Name  (if different)    
 

PAYMENT FOR SERVICE: By virtue of submitting this form, I understand that I am financially responsible for all charges incurred for services rendered. I hereby assign payment of all insurance benefits to California Advanced Gastroenterology and/or David J Schneiderman, MD

AUTHORIZATION TO RELEASE MEDICAL INFORMATION. By virtue of submitting this form,  I authorize the release of my medical records by mail, fax, electronics, or telephone to the physician or physicians from whom and/or to whom I may be referred. I also authorize the release of any medical information necessary to process insurance claims