Procedure Form PH5435 Patient Form2

2630 Grant Line Road

New Albany, IN 47150

812-945-0145 ph

812-949-5435 fx

Thank you for choosing Gastroenterology Health Partners

for your digestive health. Please complete the three

attached forms and then either:

paperless.

Please fill in all information listed below to assure your appointment is scheduled for your convenience

and all major health issues are taken into consideration for safety of your preparation prior to the

YOU ARE SEDATED FOR THESE PROCEDURES AND WILL NEED SOMEONE TO DRIVE YOU

HOME AFTERWARD.

Patient:___________________________________ DOB:___________________

Is there any specific date(s) not good for you? _________________________________

Are you allergic to latex? yes no

Are you a diabetic? yes no

If yes, controlled by: Diet

Medicine

Name: _______________________________________

Heart disease ________________________

Blood thinner ________________________

Do you have an artificial heart valve? yes no

If yes, do you receive antibiotics prior to dental work or surgery? yes no

Do you have a pacemaker? Yes no

If yes, list brand and model________________________________________________