Patient Forms

Release of Information

This form allows RGA to release the necessary information to your insurance provider. It also permits RGA to obtain medical records from your other physicians, including x-rays and hospital reports.

Release of Information

Patient History

This comprehensive 4 page form gathers your current and past medical history, as well as medications, allergy and family histories. It is an important part of your visit, and allows our physicians to evaluate your complete medical history as it relates to your digestive health needs.

Patient History

Privacy Notice

Protecting your medical privacy is one of the fundamental principles of the physician-patient relationship and of the utmost importance.

Privacy Notice

Referral Form

Providers can complete and return this form to expedite the referral process and ensure the details of your patient’s visit to RGA.

Patient Referral Form