Without complete and current medical information, you are at risk of misdiagnosis. It is in your interest to provide us with complete medical information. You do not have to waste time filling out forms in the waiting room! All the doctors you see are required to provide one copy of your record at no charge to you.

Please fill out, print and bring with you the following forms. Each form is available in PDF format, or as a Word document. Please use the version that works best on your computer. An essential requirement of cost-effective care is an informed patient!

If you are seeing us for the first time or after 2 years:

Download the form (Health History) to your computer using the link below. This is an "exe" file and has NO virus. If you have developed new medical problems, or if you are seeing other doctors, please update your record and bring us a printed copy or this file on a disk. Fill this electronic form at home to avoid wasting your time filling forms in the office. You will be seen quicker if your forms are complete. This will also be your PERSONAL HEALTH RECORD. Keep it updated. Keep it on a secure portable media to avoid medical errors in an emergency.

Health History and Demographic information

If you had procedures elsewhere, please fill out this form to help us get your medical records:

  • Release Health Information (PDF)     Release Health Information (Microsoft Word)
  • You are encouraged to keep your medical record in a digital form. Please bring a USB key( flash drive). Any brand will do. If you cannot afford this, please have an email address available before you see us. We can send the record to you in a secure form.

Your rights and responsibilities:


We accept most private insurance plans, PPO programs, and Medicaid. We will pre-qualify you for procedures and work to solve your insurance issues. If you do not have medical insurance we will do our best to help you get the needed procedures at an affordable price. Please contact us for more information.

We strive to provide you with cost-effective, high-quality care. You will receive a single bill that includes both the facility fee and the Physician's technical component fee from our endoscopy center Pathology/lab services will be billed separately by the pathologist. The pathologist is a doctor who reviews the tissue specimens or labs collected at endoscopy. If X-rays are ordered after the procedure, the radiologist will bill you separately for the services.

You will receive a detailed endoscopy and histopathology report, relevant photographs at no additional cost. Similar information is instantly transmitted to your referring doctor or family physician with appropriate recommendations.