FORMS
New Patient Forms
Patient Registration – demographics, insurance, contacts
Consent for Treatment & HIPAA Acknowledgment
Financial Policy / Assignment of Benefits – billing & payment terms
Records Release (ROI) – obtain/send medical records
Medical History & Medication List
Review of Systems Questionnaire
Prescription Refill Policy
Consent for Minor Treatment
Endoscopy / Procedure Center Forms
Pre-Procedure
Procedure Consent (EGD, Colonoscopy, Polypectomy, Biopsy, etc.)
Anesthesia / Sedation Consent
Pre-Procedure Checklist (NPO, meds, allergies, anticoagulants, devices, OSA)
Pregnancy Test Consent/Decline (when applicable)
Advance Directive / Code Status acknowledgment
Intra-Procedure
[Procedure Safety Checklist (“Time-Out”)]
[Nursing Assessment & Sedation Record]
Compliance & Safety Forms
[OSHA / Bloodborne Pathogen Acknowledgment]
[Incident / Adverse Event Report Form]
[Emergency Transfer Agreement]
[Consent for Photography/Video (if used for education/records)]
Post-Procedure
[Discharge Instructions (tailored to procedure type)]
[Escort Verification (driver/family sign-out)]
[Pathology Release Consent]
CONTACT US
Have questions or need to schedule a visit? Our team is here to listen and provide the support you need for better health.
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Book Your Appointment Today
Take the first step toward better digestive health. Schedule your visit with Dr. Ezeoke and our dedicated care team today