c,ornrnonwea/th 9 +, Gastroenterology Commonwealth Gastroenterology 4000A Glenside Dr. Henrico, VA 23228 Phone: 804-716-6318 Fax: 804-801-5187 t"atient Demographic lntormat1on Form Must Be Com�leted In Full Patient Name: Gender: Patient Address: Patient Mailing Address (if different than above): Birthdate: Marital Status: Email Address: Home Phone Number: Cell Phone: Social Security Number: Is this person a HIPAA approved contact to speak Emergency Contact Name and Relationship: Work Phone: Emergency Contact Phone Number: to about your medical information? YES NO Pharmacy Name and Address: Pharmacy Phone Number: Insurance Information Primary Insurance Policy #: Phone#: Plan ID:/ Subscriber DOB: Primary Care Provider: Carrier: Group#:/ Address: Subscriber Name: Secondary Insurance Carrier: Policy#: Group#: Phone#: Address: Plan ID: Subscriber Name: Subscriber DOB: Disclosure I hereby certify that the information I have given is correct and true to the best of my knowledge. I hereby assign Commonwealth Gastroenterology, PC any and all rights and benefits pertaining to their services rendered under any insurance policies, and I authorize said Physicians to release whatever medical information necessary to file said insurance claims and release information necessary for my care and treatment to other professional healthcare providers. I understand that regardless of my insurance status, I am ultimately financially responsible for all charges arising for the treatment of myself (or the above named patient, if applicable). If this contract is referred to a collection agency or attorney for collection, I agree to pay all court costs, including attorneys and collection agency fees in the amount of thirty percent (30%) of all total indebtedness due. Signature Date Consent To Treat T he undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and authorizes services, by Commonwealth Gastroenterology, PC (Dr. Scott D. Woogen). Signature Date Review Of S stems Cardiovascular •□ None chest pain irregular heart beat palpitations Constitutional 0 None fatigue fever loss of appetite sweats weight gain weight loss ENMT 0 None difficulty swallowing dizziness ear pain nose bleeds sore throat hearing loss Endocrine 0 None excessive thirst hair loss heat intolerance Eyes 0 None double vision loss of vision Gastrointestinal 0 None y ---,ab_d.,...o _m..,.in_a.,...I -pa....,.in _________, abdominal swelling change in bowel habits constipation diarrhea gas heartburn jaundice nausea rectal bleeding stomach cramps vomiting difficulty swallowing Genitourinary 0 None dark urine decrease in urine flow frequent urinary infections frequent urination Hematologic/Lymphatic 0 None easy bruising lntegumentary C) None hives itching lesions rashes Musculoskeletal 0 None back pain gout joint pain muscle weakness Neurological 0 None dizziness fainting frequent headaches numbness or tingling vertigo memory loss Psychiatric 0 None anxiety depression nervousness panic attacks paranoia Respiratory C) None asthma cough wheezing