Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Gastroenterology/Hepatology Consultation and
Transcript
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. ____________
