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If you do not hear back us within 1-2 business days or wish to make your appointment request over the phone please call our (214) 617-2000.

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    Prior GI Work Up: Have You Ever Seen A Gastroenterologist/Colorectal Surgeon or Had An Endoscopy/Colonoscopy?

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    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")

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    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. 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!

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