Appointment Request

To request an appointment please fill out, as complete as you can, the fields below and click submit. We will do our best to provide you with the appointment date and time you request. Use of this online appointment request service constitutes that you have read and agree with the privacy and terms of use of our practice and our website.

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 (214-972) 617-2000.

Do NOT use the appointment request below for urgent requests or emergencies. If you have an urgent gastrointestinal problem please visit your local ER. If you are having an emergency, please dial 911.

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Appointment Request Form
To request an appointment please fill out, as complete as you can, the fields below and click submit. We will do our best to provide you with the appointment date and time you request. Use of this online appointment request service constitutes that you have read and agree with the privacy and terms of use of our practice and our website.
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 (214-972) 617-2000.
Do NOT use the appointment request below for urgent requests or emergencies. If you have an urgent gastrointestinal problem please visit your local ER. If you are having an emergency, please dial 911.
Full Legal Name
Gender
Date of Birth
Home Phone Number
Mobile Phone Number
Office Phone Number
Prior GI Work Up
If Yes, please briefly describe your work up including all previous procedures and their dates and the gastroenterologist who treated you.
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Referring Doctor
Primary Care Doctor
Reason For Office Visit
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Disclaimer

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!

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