SGI Pediatric New Patient Paperwork

  • Southeastern Gastroenterology Pediatrics New Patient Paperwork

  • Southeastern Gastroenterology New Patient Demographics

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  • Gender
  • Pronouns
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Primary Phone is:
  • Can this number receive voicemail with health information?
  • Race:
  • Ethnicity:
  • With whom does the child live?
  • Who has legal custody of the child?
  • Is there a legal document indicating who is responsible for health coverage?

  • Parent's Demographics

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

  • I certify that the above information is correct. I consent to be treated by the staff and providers of, Southeastern Gastroenterology Associates, PC and its affiliates. I authorize payment of medical benefits to Southeastern Gastroenterology Associates, PC and its affiliates, and authorize them to release any medical information necessary to process claims. I understand that I am responsible for co-payments, deductibles, co-insurance, and non-covered services.

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  • Southeastern Gastroenterology Pediatric New Patient Health History

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Rows
  • Patient Medical History: Check all that apply
  • Rows
  • Rows
  • Rows
  • Is the patient adopted?
  • Is the patient in foster care?
  • Is the patient missing school?
  • Is the patient missing school activities?
  • Current Diet for Infants
  • Current diet for 1 year or older
  • Is the patient experiencing any of the following? Check all that apply.
  • Have you been experiencing Abdominal Pain?
  • If yes, is the pain:
  • If yes, when did the pain first start?
  • If yes, does the pain feel like:
  • If yes, is the pain located:
  • Have you been experiencing constipation?
  • If yes, is the constipation
  • If yes, did the constipation start:
  • Have you experienced diarrhea or loose stools?
  • If yes, is the diarrhea:
  • If yes, did the diarrhea first start:
  • Have you been experiencing nausea or vomiting?
  • If yes, is the nausea/vomiting:
  • If yes, did the nausea/vomiting start:
  • If yes, how often are you nauseous or vomiting?
  • Have you experienced difficulty swallowing?
  • If yes, is the swallowing:
  • If yes, did the difficulty swallowing first start:
  • If yes, do you have difficulty swallowing with:
  • Have you experienced rectal bleeding?
  • If yes, is the rectal bleeding:
  • If yes, did the rectal bleeding first start:
  • If yes, do you see blood in:
  • If yes, would you describe the blood as:
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  • Southeastern Gastroenterology New Patient Alternative Communication Release 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.

  • Rows
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  • Southeastern Gastroenterology New Patient Consent to Routine Procedures and Treatments

  • Rows
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  • Southeastern Gastroenterology New Patient Financial Policy

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  • Southeastern Gastroenterology New Patient HIPAA Acknowledgement

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  • Southeastern Gastroenterology New Patient Records Release

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  • Southeastern Gastroenterology Office Visit Cancellation Policy

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  • Should be Empty: