• Southeastern Gastroenterology Established Patient Paperwork

  • Demographics

  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Patient's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Marital Status
  • Gender
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Primary phone is:
  • Race
  • Ethnicity
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Information

  • Insured's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Pharmacy Information

  • Format: (000) 000-0000.
  • I authorize Southeastern Gastroenterology Associates (SGI) to communicate electronically with pharmacies to obtain my prescription history.

  • Southeastern Gastroenterology Communication Release Form

  • Please read and review the document below before completing and signing this form.
  • I authorize Southeastern Gastroenterology Associates in regards to my protected health information:

  • Right to Share Information with Family and Friends

    Southeastern Gastroenterology Associates reserves the right to communicate PHI with family or friends when it is deemed in the best interest of the patient as described in the Notice of HIPAA Policies. 

    In order to have your PHI shared in other circumstances with members of your family or friends, please list the individuals that we are authorized to release information to.

  • Family and/or Friends:
    Rows
  • Patient Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Southeastern Gastroenterology Financial Policy

  • Please review the document below before signing this form.
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Southeastern Gastroenterology HIPAA Acknowledgement

  • Please review the document below before signing this form.
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Southeastern Gastroenterology Records Release

  • Please review the document below before signing this form.
  • Patient's Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year

  • Southeastern Gastroenterology Consent to Treatment Form

  • Please review the document below before signing this form.
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Southeastern Gastroenterology Office Visit Cancellation Policy

  • Please review this document completely before signing below.
  • Today's Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: