Patient Registration
Gastroenterology Consultants of Greater Lowell
Please present all insurance cards for photocopy before registering. Thank you.
Name: _________________________________ Date of Birth:____/____/_____
(last)
(first)
(M.I.)
Address:___________________________________________________________
(street)
(apt. no.)
(city/town)
(state)
(zip code)
Home Phone No: (___)_____________ Social Security Number:_____________
Cell Phone No: (___)_________________
Please Check: Male___ Female__ Single___ Married___ Divorced__ Widowed___
Race: Caucasian _____ Hispanic ____ African American ____ Asian ____ Other __________
Ethnic: ___________________________
Language: __________________________
Employer:____________________________ Telephone No.: (___)____________
Name & Telephone Number of a Friend or Relative Residing at a Different Address:
___________________________________________(___)_______________
Name of Primary Care Physician:_________________________________
Insurance: ____________________________
(Primary)
__________________________
(Secondary)
Name of Insured Person: ______________________ Date of Birth ___/___/____
(Subscriber)
Subscriber's Social Security Number: _______________ Relation to Patient:_________
Prescription Coverage: ______________________ ID #____________________
Pharmacy Name & Address: ___________________________________________
Pharmacy Phone Number: ____________________________________________
Mail Pharmacy Name & Address: ______________________________________
Mail Pharmacy Phone Number: _____________________________________
Mail Pharmacy Fax Number: _____________________________________
Patients Email Address: _______________________________________________
Gastroenterology Consultants of Greater Lowell
Patient Medical and Surgical History
Name: _________________________________Age: __________Date: _______________
Primary Care M.D. _____________________________________________________________________
Reason for Today’s Visit ________________________________________________________________
Medications
Please list all current medications, including over the counter medications and supplements
_____________________________________________________________________________________
_____________________________________________________________________________________
Drug Allergies
Drug Allergies, please write them here.
_____________________________________________________________________________________
Medical History
Please check all areas that apply to your medical history.
__ heart attack
__ lung disease
__ gallbladder
__ hiatal hernia
__ cancer
__ chest pain
__ asthma
__ liver disease
__ gastric reflux
__ arthritis
__ Heart murmur
__ tuberculosis
__ jaundice
__ diabetics
__ psychiatric
__ blood pressure problems
__ emphysema
__ hepatitis
__ thyroid problems __ blood clot
__ kidney disease
__ seizure
__ anemia
__ shortness of breath __ ulcers
__ prostate problems
__ stroke
__ bowel problems __ bleeding problems
__ high cholesterol
Surgical History
Please list all previous major surgeries
_____________________________________________________________________________________
_____________________________________________________________________________________
If you had surgery, did you have any problems with anesthasia? Please describe. __________________
___________________________________________________________________________________
Social History
Do you smoke?
Y/N number of years ______
History of drug addiction or use of illegal drug. Y/N
Do you drink alcohol? Y/N How Often? _____________ Do you have a history of sleep apnea? Y/N
Married __
Divorced __
Single __
Widowed __
Number of Children ____
Work status: Homemaker: __ Working __ Unemployed __ Retired __ Disabled __
Occupation ____________________________________________________________________________
Family History
Do you have a family history of Colon Cancer? Y/N (father, mother, siblings, or children)
Do you have a family history of Colon Polyps? Y/N (father, mother, siblings, or children)
Gastroenterology Consultants of Greater Lowell
Are you experiencing any of the following (Please check all that apply):
Do you consider yourself generally:( ) Healthy ( ) Not Healthy (
) Other _______________
Allergic: ( ) Eye Irritation ( ) Reactions ( ) Sneezing ( ) Other _________________
( ) None
Eyes:
( ) None
( ) Blurred Vision
Ears, Nose, Throat, Mouth:
Endocrine:
( ) Pain
( ) Nose Blocked
( ) Post Nasal Drip
( ) Teeth Pain
( ) Cold Intolerance
( ) Hot flashes
Respiratory/Lungs:
( ) Irritation from Light ( ) Other __________
( ) Itching
( ) Pressure is Ears
( ) Runny Nose
( ) Other ____________
( ) None
( ) Hair Loss/Growth
( ) Heat Intolerance
( ) Other ____________________
( ) None
( ) Cough
( ) Asthma or COPD ( ) Shortness of Breath while sitting
( ) Wheezing ( ) Other __________________
( ) None
Cardiovascular/Heart: ( ) Pain in Chest
( ) Palpitations/Fluttering of Heart
( ) Shortness of Breath while exercising
( ) Other __________
Gastroenterology/Stomach:
( ) Pain
( ) Constipation
( ) Diarrhea
( ) Reflux/Heartburn
( ) Other: _________________
Hematology: ( ) Bleed Easily
( ) Night Sweats
( ) Weight Loss
Genitourinary: ( ) Urination at Night ( ) Hesitation when urinating
( ) Other ___________________
Musculoskeletal: ( ) Soreness
( ) Weakness
( ) Cramping
Skin: ( ) Sores
( ) Dry Skin ( ) Itchy Skin ( ) Rash
( ) Other ____________________
( ) None
( ) None
( ) Other ________ ( ) None
( ) Pain when urinating
( ) None
( ) Other __________ ( ) None
( ) Lesions Where___________
( ) None
Neurologic:
( ) Twitch
( ) Ringing in ears ( ) Abnormal movements ( ) Headaches
( ) Dizziness/Vertigo ( ) Fainting ( ) Other __________________
( ) None
Psychiatric:
( ) Situational Stress ( ) Anxiety
( ) Other ___________
( ) Depression
( ) Mood Swings
( ) None
Gastroenterology Consultants of Greater Lowell
20 Research Place Suite 220
North Chelmsford, MA 01863
Telephone # 978-459-6737
Fax # 978-937-7538
Patient name_______________________________
Birthdate ________________________
HIPAA Notice of Patient Privacy Practices
OUR PROMISE OF PRIVACY AND CONSENT TO PATIENT RECORDS
Our Office is fully committed to compliance with HIPAA guidelines by:
 Providing appropriate security for our patient records
 Protecting the privacy of our patient’s medical information
 Appropriately maintaining our patient information and billing processes in compliance with national standards.
If you have any questions or concerns about your service or charges, we encourage you to call the office at 978-459-6737.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to
object of withdraw as provided in this notice. For more information about HIPAA or to file a compliant:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202)619-0257
Toll Free: 1-877-696-6775
This notice was published and becomes effective on/or before April 14, 2003. We are required by law to maintain the privacy of, and
provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have
any objections to this form, please ask to speack with our HIPPA Compliance Officer in person or by phone at our Main Phone
Number.
I acknowledge receipt of the Gastoenterology Consultants of Greater Lowell privacy notice. I may request an additional copy of the
privacy notice at any time.
_______________________________________________
_________________
Signature
Date
Assignment of Benefits
Gastoenterology Consultants of Greater Lowell receives payment for patient care from insurance companies, Medicare,
and/or other third party programs.
I agree to have my insurance company, Medicare, or other third party payment program make payments directly to
Gastoenterology Consultants of Greater Lowell .
I agree to let my doctor(s) submit claims and required treatment information to my insurance company, Medicare, or
other third party payment program for my care, and receive payments directly.
I understand that I must pay all charges, co-payments, and deductibles that are not covered by my insurance
company, Medicare, or third party payment program.
_______________________________________________
_________________
Signature
Date
Gastroenterology Consultants of Greater Lowell
20 Research Place Suite 220
North Chelmsford, MA 01863
Telephone # 978-459-6737
Fax # 978-937-7538
Patient name_______________________________
Birthdate ____________________________
Permission to Communicate with Your Primary Care Physician, Other Community Care Providers and/or Mental Health
Providers:
In order to ensure continuity of care, it is often necessary to communicate information to your primary care physician and
other community care providers including mental health providers, and to your insurance company. These
communications may include information about your medical treatment and mental health or substance abuse
treatment. This information is limited to that which is necessary to the determination of coverage and the coordination of
your care.
Many insurance companies require us to document whether or not you will allow your clinician to communicate with your
primary care physician, health insurance company and/or mental health providers.
_______________________________________________
_________________
Signature
Date
Consent for RX Hub Inquiry
I hereby provide my consent for Gastoenterology Consultants of Greater Lowell to obtain my Rx History using the
SureScripts-RxHub network. I understand that this inquiry will provide my physician with an accounting of my medication
history reported by Pharmacy Benefit Managers and retail pharmacies. I also understand that SureScripts-Rx Hub has
certified that Rx History Capture follows strict security protocols to align with HIPAA requirements and respect patient
privacy. All queries and responses are made automatically through secure system-to-system communications.
_______________________________________________
_________________
Signature
Date