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Lab Results

Greater Cincinnati Pancreatic & Biliary Center

New Patients Medical History

Please complete this form in its entirety to allow us to best serve your health care needs. The information is strictly confidential, and will not be released unless you authorize us to do so, or as required by law.

Patient Information

First Name:

Last Name:

MI:

Date of Birth:

MM: DD: YYYY:

Social Security:

Email:

Sex:

Female Male

Marital Status:

Single Married Divorced Widowed

Address:

City:

State: ZipCode:

Home Phone:

Work Phone:

Occupation:

Employer:

Referring Physician:

Phone:

Family Physician:

Phone:

Reason for referral:

Emergency Contact Person:

Phone:

PRIMARY INSURANCE:

Policy:

Subscriber Name:

Date of Birth:

MM: DD: YYYY:

Social Security:

Relationship to you:

Policy holder's occupation:

Employer:

SECONDARY INSURANCE:

Policy:

Subscriber Name:

Date of Birth:

MM: DD: YYYY:

Social Security:

Relationship to you:

Policy holder's occupation:

Employer:

Current Medications

List all medications (prescriptions and over-the-counter), by name or by type, that you are currently taking, including Aspirin, Vitamins, Iron-supplements, etc.

Allergies

List all medical allergies and reactions.

Past Medical History

List all past surgeries and medical history which required hospitalization - include year.

Medical Problems Not Requiring Hospitalization

(Diabetes, High Blood Pressure, Hepatitis, Gallstones, Ulcers, etc.

Family History

	SEX	AGE	HEALTH PROBLEMS	CAUSE OF DEATH	AGE AT DEATH
Father:
Mother:
Brother/Sisters:
	M F
	M F
	M F
Spouse:	M F
Children:
	M F
	M F
	M F

Review of Symptoms

Are you experiencing any of the following?

Do You Have a Family History of:

Colon Polyps	Yes No	Other Cancers	Yes No
Colon Cancer	Yes No

Financial Responsibility Policy

It is the policy of this office that all patients, or their guarantors, are financially responsible for the services provided by the Gastroenterology Consultants of Greater Cincinnati. We expect co-pays and deductibles to be made at the time of service. The office asks that all patients assign all insurance company payments directly to the practice to avoid any misunderstandings regarding payment for professional services. The patient will be responsible for any portion of his or her bill that is not covered by the insurance carrier. If your insurance requires that you have a referral from your Primary Care Physician, it is your ultimate responsibility to ensure that our office receives that referral before your visit. If that is not done, you will be responsible to pay for the provided services. We accept Visa and MasterCard. If you need to set up a payment plan, please contact our billing department. Thank you for your understanding and cooperation with this policy.

Patient Authorization

I hearby assign all medical/surgical benefits for which a claim has been submitted by this office, to which I am entitled, to Gastroenterology Consultants of Greater Cincinnati, Inc. This will remain in effect until revoked by me in writing. A photocopy is to be considered as valid as an original. I authorize release of any pertinent medical information to my insurance company as requested in order to secure payment. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES, WHETHER OR NOT PAID BY SAID INSURANCE.

Name of the Patient:

Name of the Guarantor:

Relationship to Patient:

Date: