Gastroenterology Treatment and Practice Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: _______________ Date: _________________________

Agreement Terms

1. Consent for Treatment

I hereby authorize Dr. _________________ and associates to provide gastroenterological evaluation and treatment. I understand that this may include:

• Diagnostic procedures
• Endoscopic examinations
• Medication management
• Laboratory testing
• Medical imaging

2. Financial Responsibility

• I understand that I am responsible for all charges not covered by insurance
• Co-payments are due at the time of service
• Cancellation requires 24-hour notice to avoid fees

3. Practice Policies

I agree to:

• Provide accurate medical history and medication information
• Follow prescribed treatment plans
• Attend scheduled appointments
• Notify the office of any changes in symptoms or medications
• Maintain current contact and insurance information

4. Procedure Preparation

I understand that:

• Specific preparation instructions must be followed for procedures
• Failure to follow instructions may result in cancellation
• A responsible adult must accompany me for sedated procedures

5. Communication

I consent to:

• Receive appointment reminders
• Be contacted regarding test results
• Participate in telehealth visits when appropriate

Signatures

Patient Signature: _________________ Date: _________________

Provider Signature: ________________ Date: _________________

Office Use Only

Reviewed by: _____________________ Date: _________________