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