Patient Request for GI Appointment

For your convenience, please complete this online form. We will contact you with the appointment date/ time within 24 business hours. For questions/ concerns, contact us at 706-548-0058. Thank you for choosing Athens Gastroenterology Center for your GI healthcare!

Referring Physician:

value="" name="referring_physician" type="text" class="form-control" id="physician">

*Patient First Name:

value="" name="first_name" type="text" class="form-control" id="name" required>

*Patient Last Name:

value="" name="last_name" type="text" class="form-control" id="l-name" required>

*Date of Birth: (mm/dd/yyyy)

value="" name="birth" type="text" class="form-control" id="birth" required>

*Male/Female/Transgender:

type="radio" value="Male" name="gender" required>Male type="radio" value="Female" name="gender" required>Female type="radio" value="Transgender" name="gender" required>Transgender

*Phone:

value="" name="phone" type="text" class="form-control" id="phone" required>

*Cell:

value="" name="cell" type="text" class="form-control" id="cell" required>

Email:

value="" name="email" type="email" class="form-control" id="email">

Please be sure any medical records pertaining to the reason for visit, such as: Last office note, recent lab results, GI Radiology, Endoscopy Reports, GI Pathology Reports, and your insurance card are faxed to 706-548-0555 or bring it with you to your office appointment.

Symptom(s) or Reason for Appointment:*

value="" name="appointment" type="text" class="form-control" id="app" required>

If your insurance requires a referral authorization, please have your Primary Care Physician fax the authorization # to 706-548-0555. This referral will need to have an authorization number from the insurance company in order to cover your GI visit.

No Insurance/ Cash Patient:

value="1" name="cash" type="checkbox" class="" id="cash">

Primary Insurance:

value="" name="primary_insurance" type="text" class="form-control" id="insurance">

ID #:

value="" name="primary_insurance_id" type="text" class="form-control" id="ide">

Group #:

value="" name="primary_insurance_group" type="text" class="form-control" id="grp">

Secondary Insurance:

value="" name="secondary_insurance" type="text" class="form-control" id="sec-ins">

ID #:

value="" name="secondary_insurance_id" type="text" class="form-control" id="idf">

Group #:

value="" name="secondary_insurance_group" type="text" class="form-control" id="grp2">

We will contact you with your appointment information.

THANK YOU AGAIN FOR ALLOWING US TO BE PART OF YOUR HEALTHCARE TEAM!

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