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:

*Patient First Name:

*Patient Last Name:

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

*Male/Female/Transgender:

Male Female Transgender

*Phone:

*Cell:

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:*

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:

Primary Insurance:

ID #:

Group #:

Secondary Insurance:

ID #:

Group #:

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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