Patient Registration Forms

TEANECK GASTROENTEROLOGY ASSOCIATES, PA

DRS. SCHMIDT, MICALE, PALANCE, LIN, WELINSKY AND LACEY HERALD, PA-C
Thank you for choosing the office of TEANECK GASTROENTEROLOGY ASSOCIATES, PA. You will receive an automated phone call to confirm your appointment 3 days in advance of your appointment date. Please make every effort to Confirm and keep your scheduled appointment.
FULL PATIENT NAME (FIRST AND LAST)*
APPOINTMENT DATE

MonthDayYear
Date
APPOINTMENT TIME
If you cannot complete these forms electronically, BRING THEM on the day of your visit. If you are unable to complete them on your own, please have a family member assist you or come to your appointment 30 minutes early so we can assist you.

Bring a complete list of your CURRENT MEDICATIONS.

Bring any RECENT LAB RESULTS, CT SCANs, MRIs or ULTRASOUNDS of the Abdomen, or any testing that is related to the reason why you are seeing the doctor.

Bring your INSURANCE CARDS, PHOTO IDENTIFICATION and ANY NECESSARY REFERRAL from your primary care physician.

PAYMENT is expected as services are rendered. Please be prepared to pay your copay at the time of your visit. We gladly accept cash, checks, American Express, Discover, Visa and MasterCard.
DIRECTIONS FOR GPS, PLEASE USE THE FOLLOWING ADDRESS:
1092 KATHERINE STREET, TEANECK, NJ
PATIENT REGISTRATION FORM
FIRST AND LAST NAME
Date of Birth*

MonthDayYear
Date
GENDER AT BIRTH*

malefemale
GENDER IDENTITY*

malefemale
Address*

Address

Street Address Line 2

CITYSTATE

ZIP
Cell Phone*
Please enter a valid phone number.
Home Phone
Work Phone
MARITAL STATUS*

singlemarrieddivorcedwidowedlegally separated
ETHNICITY

HISPANICNOT HISPANIC
RACE

American IndianAlaskanAsianBlackMixed RaceCaucasianPacific Islandder
PRIMARY LANGUAGE
YOUR EMPLOYER
Occupation
Your Employer Address
PARTY TO NOTIFY IN CASE OF EMERGENCY*
PHONE NUMBER*
RELATIONSHIP*
The PATIENT PORTAL gives our patients secure, up to the minute access to their medical records, diet and educational forms, appointment, refill, billinghistoryand statements. PLEASE NOTE: PATIENT PORTAL ACCESS REQUIRES AN E-MAIL ADDRESS.
YOUR E-MAIL ADDRESS
Would you like to receive paperless billing statements through the patient portal?

YesNo
Primary Care Physician (doctor's name, not group name)
Phone
Primary Care Address
Referring Physician (doctor's name, not group name)
Phone
Referring Provider Address
OUR PRACTICE SENDS PRESCRIPTIONS ELECTRONICALLY. THIS REQUIRES YOUR PHARMACY INFORMATION.
Local Pharmacy Name*
City*
Phone
Mail Order Pharmacy
PRIMARY INSURANCE NAME
ID
SUBSCRIBER
DOB
SECONDARY INSURANCE
ID
SUBSCRIBER
DOB
I understand that I am responsible for my bill. I understand that if my insurance requires a referral, I will provide it at the time of my visit or reschedule until such time as I can provide the necessary referral. I authorize Drs. Schmidt, Micale, Palance, Lin, Welinsky and/or their employees to:

Release any information to my insurance companies necessary for processing my insurance claim. A copy of this authorization can be used in place of the original. Receive direct payment from my insurance companies Release to and receive from any laboratories, hospitals, doctors or other healthcare providers, any information regarding my medical condition(s) and medical history necessary to treat me and coordinate my healthcare. Leave results of the tests performed on me, which are considered within normal limits for my health status, on my home telephone recording device, cell phone, e-mail or given to a spouse or family member. Call me at work to remind me of my appointment or to request a return call. This request can also be left with a spouse, family member or on a home telephone recording device, cell phone or e-mail or Text Message. Download my pharmacy benefits and my e-prescribe history Communicate with me through the Patient Portal Send my statement via the Patient Portal (only when providing an e-mail address) Use Jot Form to obtain demographic and health history information, use text messaging to sent links for video calls and appointment reminders.
Patient Signature*

Clear
TEANECK GASTROENTEROLOGY ASSOCIATES, PA
PRINT Patient Name*
Date of Birth*

MonthDayYear
Date
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that under the Health Information Portability & Accountability Act of 1996 (HIPAA), , I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment, directly or indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. Notification of any breaches in unsecured Protected Health Information

I have received and read and understand your Notices of Privacy Practices containing a more complete description of the usesand

disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact his organization to obtain a copy of the Notice of Privacy Practices.

I understand that I may request, in writing, that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand that you are not required to agree to my requested restrictions, but if you do agree, they you are bound to abide by such restrictions.
Signature*

Clear
Date

MonthDayYear
Date
I will allow Drs Schmidt, Micale, Palance, Lin & Welinsky or their designees to discuss my protected health information with the following person(s) listed below:
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
HEALTH HISTORY
NAME*
DOB*
(Today's Date

MonthDayYear
Date
CHIEF COMPLAINT: (What brings you here today?)
PAST MEDICAL HISTORY

AnemiaDiabetesAsthmaHeart DiseaseCancerHerniaJoint ReplacementHIV/AIDSStrokeColon PolypsHigh Blood PressureCirrhosisNO SIGNIFICANT PAST MEDICAL HISTORYPneumoniaUlcersKidney DiseaseOther
Any recent travel outside of the country?*

yesno
Where?
PAST SURGICAL HISTORY: List any surgeries you have had, where they were performed and the approximate year. Please be sure to specifically include any surgeries of the abdomen, chest, head and neck. If none, please indicate NONE.
Surgery
Doctor/Facility
When
Surgery
Doctor/Facility
When
Surgery
Doctor/Facility
When
Surgery
Doctor/Facility
When
Have you ever had a colonoscopy before?

YesNo
Where
When
Have you ever had an upper endoscopy before?

YesNo
When
Where
MEDICATIONS: Please List ALL Medications you take, both Prescription and Over the Counter. If you take NO MEDICATIONS, please indicate NONE.
Medications
DID YOU RECEIVE THE COVID VACCINE?

YN
When
Please Choose

PfizerModernaJ & J
ALLERGIES - Please list any and all allergies in the appropriate category, or indicate NONE
DRUG ALLERGIES
FOOD ALLERGIES
ENVIRONMENTAL ALLERGIES
DO YOU HAVE AN ALLERGY TO IV CONTRAST

YESNO
DO YOU HAVE AN ALLERGY TO IODINE?

YESNO
ANY PROBLEMS WITH ANESTHESIA IN THE PAST?

YESNO
SOCIAL HISTORY: Please indicate which of the following substances you use and the frequency of use:
TOBACCO HISTORY*

NeverPreviously but quitYES# Packs per day# of years smoking
VAPING HISTORY*

YESPREVIOUSLY BUT QUITNEVER
Alcohol?*

NeverRarelySociallyModeratelyDaily
# of drinks per day
Drugs?*

NeverPreviously but quit IV Drugs?YESNO
Caffeine?*

NeverRarelySociallyModeratelyDaily
# of drinks per day
Name
DOB
FAMILY HISTORY: Please tell us about your family history. Be sure to include cancers of all kinds as well as those of the GI tract and liver.
Is you Mother still living?

YesNo
Mother's chronic diseases or cause of death
Is your Father still living?

YesNo
Father's chronic diseases or cause of death
Is your Sister still living?

YesNo
Sister's chronic diseases or cause of death
Is your Brother still living?

YesNo
Brother's chronic diseases or cause of death
REVIEW OF SYSTEMS - PLEASE CHECK ALL THAT APPLY

Weight GainWeight LossSwellingShortness of BreathChest PainSleep ApneaEmphysemaWheezingChronic CoughRectal BleedingPainful Bowel MovementsNauseaVomitingChange in bowel movementsAbdominal PainConstipationLoss of AppetiteDiarrheaHemorrhoidsHepatitisAnorexiagas/bloatingHeartburnJaundicedifficulty swallowingblood clotsbruisingtransfusionblood thinners?Other
Name of blood thinner, if any
To the best of my knowledge, the questions on this form have been answered accurately. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I also authorize the healthcare staff to perform the necessary services I may need.

Signature of Patient, Parent or Guardian: x
Date

MonthDayYear
Date
Signature*

Clear
Should be Empty:

TEANECK GASTROENTEROLOGY ASSOCIATES, PA

DIRECTIONS FOR GPS, PLEASE USE THE FOLLOWING ADDRESS:

1092 KATHERINE STREET, TEANECK, NJ

PATIENT REGISTRATION FORM

TEANECK GASTROENTEROLOGY ASSOCIATES, PA

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

HEALTH HISTORY