john g. dowd, do jennifer nayor, md michael desimone, md · dr. john g. dowd d.o. dr. jennifer...
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Dr. John G. Dowd D.O.
Dr. Jennifer Nayor M.D.
Dr. Michael DeSimone M.D.
Concord Gastroenterology Associates 131 ORNAC, John Cuming Bldg., Suite 650 Concord, MA 01742
Ph: (978) 287-3835 * Fax: (978) 287-2979 Endoscopy/Colonoscopy: Direct Booking
Dear patient:
Please complete the enclosed patient information forms and send them back. PLEASE INCLUDE A COPY OF YOUR INSURANCE CARD(S), FRONT AND BACK. We are not able to book your appointment without a copy of your cards and completed forms. After you send the completed forms back, please allow 1 week for our office to review and call to schedule. If you don’t hear form us in this time frame, please call our office. If you have had previous procedures, please document it on the form.
Please be sure to check with your insurance company regarding coverage for all appointments. It is helpful to inquire regarding coverage for both screening and diagnostic colonoscopy procedures. Although the procedure may be scheduled as a routine preventative screening, it could be become diagnostic if any biopsy taken or diagnosis made at the time of the procedure. After scheduling your appointment, please call your primary care physician’s office to obtain a referral if applicable.
If you need to cancel or reschedule an appointment, please call us at least 7 days in advance so that we may use that appointment for another patient.
Remember, endoscopic procedures require sedation making it unsafe to drive yourself home. You must plan on a driver being available to take you home approximately three to four hours after the scheduled exam time.
I hope you will find the enclosed information helpful. I wish you well as you go through the process, and look forward to seeing you for your examination. Please do not hesitate to call with any questions or concerns.
Sincerely,
John G. Dowd, DO
Jennifer Nayor, MD
Michael DeSimone, MD
Patient’s Name ____________________________________ FORM MUST BE COMPLETED IN FULL
Concord Gastroenterology Associates
May we contact you and/or leave you messages? At home? yes/no on cellphone? yes/no at work? yes/no
Email address: _______________________________________________________________________________
Pharmacy/address/town: _______________________________________________________________________
Mail order pharmacy: __________________________________________________________________________
May we discuss your condition with anyone? ( ) yes ( ) no
If yes, with whom? Name: ________________________Relationship to patient: ____________________________
Other(s): ______________________________________________________________________________________
Who may we contact in case of an emergency? _______________________________________________________
Relationship to patient: _________________________________ Phone number: ___________________________
** IF YOUR INSURANCE REQUIRES REFERRALS YOU ARE RESPONSIBLE FOR OBTAINING THEM PRIOR TO YOUR APPOINTMENT.
YOU WILL BE RESPONSIBLE FOR ANY CHARGES INCURRED FOR UNAUTHORIZED CARE. **
Primary insurance company: ______________________________________________________________________
Subscriber’s name/ relationship: (if not patient): ______________________________ Date of birth: ____________
Insurance company address: ______________________________________________________________________
Policy#: ___________________________________________ Group#: ____________________________________
Secondary insurance company: ____________________________________________________________________
Subscriber’s name/ relationship: (if not patient) ______________________________ Date of birth: ____________
Insurance company address: ______________________________________________________________________
Policy#: __________________________________________ Group#: _____________________________________
This information is given for the purpose of establishing an account and medical file with CONCORD GASTROENTEROLOGY
ASSOCIATES. It is understood that I shall be responsible for all charges incurred by me (or any minor child as noted above). I hereby
authorize the doctor to release all information necessary to secure payment of benefits. I authorize payment for any insurance
claims be made directly to the physician.
I have received a copy of the Notices of Privacy Practices from Concord Gastroenterology Associates.
Patient Signature: ___________________________________________ Date: _____________________
Patient Representative (minor/ unable to sign): _____________________ Date: _____________________
Relationship of patient representative to patient: _______________________________________________
THIS FORM MUST BE COMPLETED IN FULL
Gastroenterology
New Patient Intake Form Today’s Date ________________________
Name ______________________________ Date of Birth ____________________________
Marital Status Married Single Widowed Divorced Other
Gender Male Female
Home Address __________________________________________________________________
Phone Numbers Home: _______________ Cell: _______________ Work: __________________ Primary
Phone is Home Cell Work
Preferred Language English Chinese (Cantonese) Chinese (Mandarin) French
Japanese Portuguese Russian Spanish
German Italian Vietnamese Arabic
Bosnian Declined to list Other __________________
EMPLOYMENT
Employer ________________________________________ Dept./ Title ________________________________
Employer’s Address ___________________________________________________________________________
PERSONAL HISTORY
Describe the reason(s) for your visit _____________________________________________________________________
__________________________________________________________________________________________________
Referred to Gastroenterology by _________________________ Primary Care Physician _______________________
Other physicians involved in your care _____________________________________________________________
1.) SOCIAL HISTORY
Provide details regarding current and/or past use of the following:
Alcohol (beer, wine, liquor) Yes No Weekly Consumption _______________________________
IV or Recreation Drugs Yes No Usage/Frequency __________________________________
Tobacco (cigarettes,cigar,chewing tobacco) Yes No Usage/Frequency __________________________________
Smoking Status Every Day Some Days Former Never Unknown
Patient’s Name ____________________________________ FORM MUST BE COMPLETED IN FULL
2.) PATIENT MEDICAL HISTORY (check all that apply)
Cirrhosis Hepatitis B Anemia High Blood Pressure Scleroderma
Colon Cancer Hepatitis C (HCV) Anxiety/Depression High Cholesterol Stroke Colon Polyps Hiatal Hernia Asthma HIV/AIDS _____________
Crohn’s Disease Irritable Bowel Cancer: __________ Irregular Heartbeat _____________
Diverticulitis Syndrome (IBS) Celiac Disease Kidney Disease _____________
Diverticulosis Liver Disease COPD/Emphysema Obesity _____________
End Stage Renal Stomach/Intestinal Diabetes Osteoporosis _____________
Disease (ESRD) Ulcers Glaucoma Pancreatitis _____________
GERD/reflux Ulcerative Colitis Heart Disease/Attack Seizures _____________ Whom is your previous Gastroenterologist(s). ________________________________________
Last Upper Endoscopy and/or Colonoscopy: When______________ Where_______________
3.) PAST SURGICAL HISTORY (check all that apply and provide dates)
Appendectomy __________________________ Hernia Surgery ____________________________ Angioplasty __________________________ Hysterectomy ____________________________ Caesarean (C section) __________________________ Nissen Fundoplication _______________________ Colon Surgery __________________________ Stomach Surgery ___________________________ Colonoscopy __________________________ Tonsils ____________________________ Gallbladder Surgery __________________________ Wisdom Teeth ____________________________ Gastric Surgery __________________________ Other? ____________________________ Heart Surgery __________________________ Other? ____________________________ Hemorrhoid Surgery __________________________ Other? ____________________________
4.) MEDICATIONS
List current medications (including herbal) and dosage
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
Do you take any antibiotics before dental or medical procedures? If yes, why? ___________________
__________________________________________________________________________________
5.) ALLERGIES
List any medication allergies No known medication allergies
__________________________________________________________________________________________
List any environmental or food allergies No known environmental allergies No known food allergies
__________________________________________________________________________________________
Patient’s Name ____________________________________ FORM MUST BE COMPLETED IN FULL
6.) FAMILY HISTORY Mother Father Siblings Son Daughter Grandmother Grandfather
Acid Reflux/GERD
Barrett’s Esophagus
Cancer
Breast
Colon
Esophagus
Lung
Lynch Specific
Pancreas
Prostate
Stomach
Other ___________
Colon Polyps
Crohn’s Disease/Colitis
Diabetes
Gallstones
Heart Problems
High Blood Pressure
High Cholesterol
Liver Disease
Stomach Ulcers
Thyroid Disease
Wheat Allergy (Celiac)
Other? ____________
Patient’s Name ____________________________________ FORM MUST BE COMPLETED IN FULL
SYSTEM REVIEW
Do you have or have you experienced any of the following in the last 6 months?
CONSTITUTIONAL
Body Aches
Chills
Fatigue
Fever
Loss of Appetite
Night Sweats
Weight Gain
Weight Loss
None of the Above
EYES Dry
Blurred Vision Dry
Visual Changes Dry
None of the Above
EARS/NOSE/THROAT
Ear Pain/Ringing
Hearing Loss
Mouth Ulcers/Sores
Nose Bleed
Problems with Gums/Teeth
Trouble Swallowing
None of the Above
SKIN
Itching/Dry Skin
Jaundice (yellow eyes or skin)
Rashes, Bumps or Sores
None of the Above
GASTROINTESTINAL
Abdominal Pain/Discomfort
Anal/Rectal Pain or Itching
Pain with Bowel Movements
Black Stool
Bloating/Belching/Gas
Change of Bowel Habits
Constipation
Diarrhea/Loose Stool
Difficulty Swallowing
Heartburn/reflux
Hemorrhoids
Indigestion
Mucus in Stool
Nausea/Vomiting
Rectal Bleeding (in stool, toilet,
toilet paper)
Unintentional Weight Loss
None of the Above
MUSCULOSKELETAL
Back Pain
Decrease Range of Motion
Joint Pain/Arthritis
Problems Walking/Leg Pain
None of the Above
GENITOURINARY
Are you pregnant?
Blood in Urine
Burning/Pain with Urination
Increased Frequency/During
Night
Recent Urinary Tract Infection
Kidney Stones
None of the Above
HEMATOLOGY/LYMPHATIC
Bleeding Problems
Enlarged Nodes/Glands
Excessive Bruising
History of Anemia
None of the Above
RESPIRATORY
Chronic Cough
Shortness of Breath
Wheezing or Asthma
None of the Above
PSYCHIATRY
Anxiety
Change in Sleep Patterns
Depression
Loss of Memory
None of the Above
NEUROLOGIC
Headache
Dizziness/Vertigo
Head Trauma/Injury
Recent Numbness/Weak
Seizures
None of the Above
CARDIOVASCULAR
Chest Pain
High Blood Pressure
Heart Murmur
Heart Racing/Skipping
Palpitations
SERVICES PROVIDED WITHOUT REFERRAL AUTHORIZATION
I understand that I have an obligation to obtain a referral from my Primary Care Physician for services.
I acknowledge that I may be responsible for payment for services received should this visit be denied by
my insurance carrier.
Additionally, some secondary insurance plans with Medicare are now requiring referrals. I understand
that I have an obligation to obtain a referral from my Primary Care Physician for Services in order for my
secondary insurance to pay.
Patient name (Print): ___________________________________________________________________
Patient date of birth: ___________________________________________________________________
Patient signature or responsible party: _____________________________________________________
Date of service: ________________________________________________________________________
EMERSON HOSPITAL
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY NOTICE
AND
CONSENT TO TREAT/ DISCLOSE HEALTH INFORMATION
ACKNOWLEDGMENT OF RECEIPT OF EMERSON’S NOTICE OF PRIVACY PRACTICES:
By my signature below, I hereby acknowledge that I have received a copy of the Notice of Privacy Practices for Emerson Hospital,
Emerson Practice Associates, Concord Gastroenterology Associates, any health care professional providing services in the Hospital’s
clinically integrated care setting, any members of our volunteer group that we allow to help you, and all employees, staff and other
Emerson Hospital personnel (collectively, "Emerson")."
CONSENT FOR TREATMENT/TO DISCLOSE MY GENERAL HEALTH INFORMATION:
By my signature below, I hereby authorize Emerson Hospital and those physicians, assistants and consultants as may be selected by
them to render such care including diagnostic procedures, medical and surgical treatment and emergent blood transfusions, which may
be necessary to care for me. I also authorize Emerson Hospital to disclose my medical information so that Emerson may treat me, seek
payment from third parties for such treatment, and generally carry on Emerson’s health care operations (e.g., quality assurance). I also
authorize Emerson to disclose my medical/insurance information to insurers and providers outside of Emerson when necessary so that
these providers may treat me, seek payment for that treatment, and for the purpose of their health care operations. I also authorize
Emerson to send me information regarding health services at Emerson Hospital.
ASSIGNMENT OF INSURANCE BENEFITS AND RIGHT OF RECOVERY
In consideration of services rendered, I hereby irrevocably assign and transfer to Emerson Hospital, its physicians, assistants and
consultants’ rights, title and interests in the benefits payable for services rendered related to this visit. If I am covered under Medicare,
I hereby certify that the information given by me in applying for payment under Title XV11 of the Social Security Act is correct. Said
irrevocable assignment and transfer shall be for the recovery on said policy(ies) of insurance, but shall not be construed to be an
obligation of Emerson Hospital to pursue any such right of recovery. Provided, however, this assignment and transfer shall not take
away my standing to sue or make claim for benefits, individually, should coverage be denied by an insurance carrier(s). I hereby
authorize my insurance company(ies) to pay directly to Emerson Hospital and its physicians, assistants, and consultants all benefits
due under said policy(ies) by reason of services rendered therein. I will pay Emerson Hospital, its physicians, assistants, and
consultants for all charges incurred or alternatively, for all charges in excess of the sums actually paid pursuant to said policy(ies) that
my providers are permitted to collect. A photostatic copy of this authorization shall be considered as effective and valid as the
original.
_________________________________________________________________ ___________________
Print Name Date
_________________________________________________________________
Signature of Patient
If the patient is an unemancipated minor or otherwise incapacitated (physically or mentally), obtain the following signatures:
_________________________________ _____________________________ ___________________
Signature of Description of Date
Personal Representative Authority