Certification American Medical Association

Full Legal Name

Gender

MaleFemale

Date of Birth

Email Address

Home Phone Number

Mobile Phone Number

Office Phone Number

Prior GI Work Up

YesNoNot Sure

Select Requested Procedure(s)

ColonoscopyEndoscopyColon Cancer ScreeningGI Genetic TestingHemorrhoid TreatmentObesity & Weight Loss

If Yes, please briefly describe your work up including all previous procedures and their dates and the gastroenterologist who treated you.

Referring Doctor (If Self Referral, Please Type "Self")

Primary Care Doctor

Primary Insurance Provider

AetnaBlue Cross Blue ShieldCignaUnited HealthcareOther

Reason For Office Visit

Disclaimers

I understand that if any of the insurance information I have provided is incorrect or if I fail to notify the office of any insurance changes that I am responsible for all physician charges and non-covered medical services.

I hereby authorize the release of any medical information necessary for the process of insurance. I hereby assign all medical and/or surgical benefits to include major medical benefits to which I am entitled to Alexander Mantas, MD, PA, Digestive Health Associates of Texas, PA and Digestive Health Management Endoscopy Centers. This assignment will remain in effect until revoked by me in writing. A photocopy of this agreement is to be considered as valid as an original. I have received the Notice of Privacy Practices.

By Submitting This Form, Patient Agrees To All Terms, Conditions & Disclaimers!

Security Question

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