Patient Forms

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What to expect when you check-in:

To protect you and your identity, our front office staff will ask for your photo identification (i.e. driver's license, passport, military ID, etc.) and insurance cards for each visit. You will also be asked to have a photo taken for your medical record, if one is not already on file.

Patient identification and insurance verification is necessary to:

  • Ensure care is provided to the correct patient now and in the future
  • Protect against identity theft
  • Comply with state and federal laws and regulations that protect the security and integrity of patient information
  • Ensure proper billing of insurance on your behalf

You will also be asked to complete and/or update patient forms. This helps to ensure that we have accurate information and helps you to identify changes in your health history.

Patient Information Forms:

  1. ATTENTION: Insurance Information
  2. Personal Medical History (pdf form revised February 4, 2015)
  3. Confidential Patient Information (pdf form revised May 9, 2016)
  4. Notice of Patients Rights & Responsibilities (pdf form revised March 8, 2016)
  5. Notice of Privacy Practices (pdf form revised June 13, 2013)
  6. Patient Payment Credit Agreement (pdf form revised April 18, 2016)
  7. Living Will and Durable Power of Attorney for Health Care

Procedure Brochures:

Patient Instructions:

  1. Colonoscopy Procedures:
  2. Colonoscopy / Upper Endoscopy Combination Procedures:

Financial Information:

Release of Information:


Samuel S. Gibson, M.D..Nic R. Cordum, M.D..Robb F. Gibson, M.D.. Stephen M. Schutz, M.D.
Mark A. Mallory, M.D..Christopher J. Goulet, M.D.. Ashley T. Evans, M.D.. Meghan Jankowski, M.D..
Tracy M. Young, F.N.P.June M. Reiling, F.N.P.