Charles River General Consent Form

YOUR DRIVER SHOULD REMAIN READILY AVAILABLE FOR TRANSPORT WHILE YOU ARE AT OUR CENTER. THEY ARE WELCOME TO REMAIN IN THE WAITING ROOM IF THEY PREFER.

**Absolutely nothing to drink (clear liquids &/or prep) for 4 hours prior to the procedure as this will delay your procedure**

Please discuss any medications that you take with your Prescribing Doctor and Gastroenterology doctor before discontinuing

Please fill out these three forms at home and bring with you on the day of your visit. You must also bring a form of identification & your insurance card(s) each time you visit our clinic. Thank you.

Last Name: ___________________ First Name: _____________________ Middle Initial: _____ Sex: M / F

Date of birth: ____/____/_____ Age: ____ Married Single Widowed (circle) Height: ____ Weight: _____lbs.

Home Phone: (______) _________________________ Cell Phone: (______) _________________________

Please put an asterisk next to the preferred phone number to call you when doing a follow up call.

Address: _______________________________________ Town & Zip Code: ________________________

Email Address: _______________________ Ethnicity: ________________ Language: _________________

Do you need a translator (circle) Yes/ No Type: Language: _____________ / Speech / Hearing / Written Material(circle)

Ride Home: _____________________________ Phone: (____) ___________ Phone: (____) ____________

(Please provide a phone number even if your ride plans to stay. Your ride must be over 18 and present within a half hour of discharge/ no taxi car service can be used without a responsible adult to accompany you)

Have you been to Charles River Endoscopy before? Yes or No

If so please write date of last procedure: __________________

AUTHORIZATION AND CONSENT FOR GENERAL TREATMENT AND BILLING

I wish to be treated at Charles River Endoscopy LLC. While in the center, I permit my doctor, Charles River Endoscopy LLC, and its employees and all other persons caring for me to treat me in the ways that they judge beneficial to me. I understand that this care may include tests, examinations, photography, the administration of medication and medical treatment.

I authorize Charles River Endoscopy LLC to furnish information and/or photocopies of my medical record for this treatment which record may or may not contain privileged information, to an insurer, compensation carrier, social security administration or welfare agency which may be providing financial assistance for my hospital care.
I hereby authorize payment directly to Charles River Endoscopy LLC of any group benefits, private policy benefits, and major medical benefits as determined by the insurance company or Medicare benefits. I also authorize payment directly to the physician or organization furnishing the services or authorize such physician or organization to submit a claim for treatment rendered, but not to exceed regular charges for the service.

I understand that I am responsible for the hospital and physician(s) charges not covered by this visit.

I permit a copy of this authorization to be used in place of the original.
I have received a copy of Charles River Endoscopy LLC’s Notice of Privacy Practices/ HIPPA.
I authorize payment of Medigap Benefits to Charles River Endoscopy LLC for services provided.

X ____________________________________________________ _________________________Patient’s Signature Date Time

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