Address

Street Address

City

State

Country

Postal Code

Full Name of Card Holder

Is this Plan:

Medicaid

Disability

Cobra

Workman's Comp.

Please List all previous surgeries and their corresponding dates

Are you aware of any problems with anesthesia? YES or NO? (If your answer is yes, please explain below)

Please list all known allergies and your corresponding reactions

Please list all current medications/vitamins. Include dosage, frequency, and reason

Medical Condition Relationship

Diabetes Mellitus
High Blood Pressure
High Cholesterol
Obesity
Stroke
Heart disease
Depression
Alcoholism
Thyroid Disorder
Cancer
Blood Disorder
Kidney Disease
Lung Disease
Other

SIGNING THIS AUTHORIZATION MEANS YOU AUTHORIZE THE RELEASE OF INFORMATION INCLUDING THE DIAGNOSIS, RECORDS, AND EXAMINATION RENDERED TO ME AND DR. ELIAS DARIDO, HOUSTON HEARTBURN & REFLUX CENTER.

2100 WEST LOOP SOUTH, SUITE 1115, HOUSTON, TX 77027 Fax : 281.762.1452.

If you have any questions please call our office at (832) 945.8717

Please List physician Name, Phone number, and Fax number

Date