Download Gastroenterology/Hepatology Consultation and

PAUL E. ZACHARY JR., MD
MANDI L. BARNES, FNP-C
1419 WESTPORT LANDING PLACE
SUITE 103
MANHATTAN, KS 66502
P 785-539-8900
F 785-539-4425
WWW.MANHATTANGASTRO.ORG
Patient Name: ____________________________ Date of Birth: _________________
SSN: __________________________ Email: _________________________________
Home Phone: ______________ Work Phone: _____________Cell Phone: ___________
Patient Address: _________________________________________________________
Insurance: ____________________________________________________
Insurance ID #_________________________________Group #___________________
Sponsor of Insurance: (Circle One)
SELF
SPOUSE
PARENT OTHER________
If other NOT self, please provide Name and Date of Birth: _______________________
Reason for Referral: _______________________________________________________
PROCEDURE(S) REQUESTED: (please circle all that apply)
GI Consult Only
EGD with BRAVO/pH
Flex Sigmoidoscopy
Colonoscopy
*ON Medication
Peg Placement
EGD
*OFF Medication
Esophageal Dilation
Do you want a GI Consult in addition to the endoscopic procedure for the patient? Y/N
If the procedure reveals significant findings that require treatment or follow up do you
want me to treat and follow up? Y/N
Referring Physician Signature: _____________________ Phone: _________________
***Please fax copies of any pertinent medical records including
progress notes, lab results and imaging studies***
Office Use Only
Drug Allergies: __________________________________ History of MRSA? YES NO
On Coumadin, ASA, PLAVIX, NSAID? YES NO
Diabetic? YES NO If yes, Insulin/oral medication_____________________________
Check in time: _________ Procedure time: ___________ Procedure date: ____________
Written &/or verbal instructions/preparations for the procedure(s) listed above were
given/sent to the patient. ____________