Registration Form

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PATIENT INFORMATION

Legal Name:


DOB:	Age:	Sex (select one):

		No Email

Employment Status:	Race:	Ethnicity:


Parent/Legal Guardian Information (Under 18) :

DOB:	Mobile No:
Title:	Marital Status:
Referral Sources:
Emergency Contact Information:

Patient Portal:

INSURANCE INFORMATION


DOB:	Phone Number:



DOB:
Patient Relationship to Insured:


DOB:
Patient Relationship to Insured:
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the provider. I understand that I am financially responsible for any balance. I also authorize Denton Family Clinic or insurance company to release any information required to process my claims

CONSENT FOR TREATMENT

By signing this consent, I am authorizing my physician and/or other individuals he/she deems appropriate to perform and/or order exams, tests, procedures, and any other care deemed necessary or advisable for the diagnosis and treatment of my medical conditions. This consent is valid for each visit I make to Denton Family Clinic unless revoked by me in writing.

Please be informed Texas allows a patient to be tested for possible exposure to the Human Immunodeficiency Virus (HIV), the virus associated with AIDS, in the following situations: 1) to screen blood, blood products, organs or tissues to determine suitability for donation; 2) if another individual is accidentally exposed to a patient’s blood or bodily fluids, such as through a needle stick (any such test shall be conducted pursuant to Denton Family Clinic infectious disease protocol) ; or 3) if a medical or surgical procedure is to be performed which could expose health care workers to the patient’s blood or bodily fluids. This disclosure is to inform you that you may be tested, at the expense of Denton Family Clinic if any of those situations occur during your treatment period.

Patient’s Printed Name:	DOB:

CONSENT FOR TREATMENT OF A MINOR (Ages 0-18* Birthday)

I give permission for Denton Family Clinic to provide confidential medical evaluation and treatment to the minor named above. I understand the care being rendered may include diagnostic testing, in office labs, surgical evaluation and contraceptive services.

Additional diagnostic testing may be sent or requested from a third -party testing facility. It is understood this authorization is given in advance of any specific diagnosis, treatment or care being required. It provides authority and power to render care to above-mentioned by the staff of Denton Family Clinic in the exercise of their best judgment. I agree to accept financial responsibility for all care and services delivered pursuant to this authorization. This authorization also grants the power to release information to any third party payers who may be responsible for part or all the cost of the services provided. I declare under penalty of perjury that the above information is true and correct. My signature signifies that I have read and understand the content of this consent.

Patient’s Printed Name:	DOB:

CONSENT FOR TELEMEDICINE SERVICES

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, theraphy, follow-up and education, and may include any of the following: Patient medical records, Medical Images, Live two-way audio and video, Output data from medical devices and sound and video files.

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Expected Benefits:

Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
More efficient medical evaluation and management.
Obtaining expertise of a distant specialist.

Possible Risks:

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultants).
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment.
In rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or other judgment error.

BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:

I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent,
I understand that I have the right to withhold or withdraw my consent to the use of telemedicine during my care at any time, without affecting my right to future care or treatment,
I understand that I have the right to inspect all information obtained and recorded during telemedicine interaction, and may receive copies of this information for a reasonable fee,
I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. Denton Family Clinic has explained the alternatives to my satisfaction,
I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
I understand that it is my duty to inform Denton Family Clinic of electronic interactions regarding my care that I may have with other healthcare providers.
I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

I have read and understand the information provided above regarding telemedicine. I hereby give my informed consent for the use of telemedicine in my medical care. I hereby authorize Denton Family Clinic to use telemedicine in the course of my diagnosis and treatment.

Patient’s Printed Name:	DOB:

FINANCIAL POLICY

Thank you for choosing Denton Family Clinic as your health care provider. We are committed to providing excellent health care services to you, our patient. As a part of our professional relationship, it is important that you have an understanding of our financial policy. All patients must read and sign this form prior to receiving services.

Expected Benefits:

It is patient responsibility to provide us with the most current insurance information at time of each visit.
Insurance will be filed for services rendered. Any charges for services not covered by insurance will be the responsibility of the patient or his/her guardian. It is patient responsibility to know insurance benefits and whether or not the services rendered are covered benefits. Our offices have no way of knowing every insurance plan benefit; patient is responsible for knowing what services are or are not covered.
We must emphasize that, as medical providers, our relationship is with the patient, and not the insurance company. Each insurance contract is between the patient, the insurance company and possibly the employer. It is patient responsibility to know and understand the level of services covered by the insurance company.
If the insurance company does not respond to our claim, a statement will be sent to the patient. The patient will have to call the insurance company to work out the claim; our office will assist the patient only after the patient has contacted the insurance.
Copayments, coinsurance and/or deductibles are due at the time of service. We will estimate the amount the patient owes based on information we receive from the insurance company. However, the patient is responsible for paying the full amount determined by the insurance company once they have paid the claim-regardless of our estimation. Failure to keep the account balance current may require us to cancel or reschedule the scheduled appointment.
It is patient responsibility to provide us with the most current billing information such as address, phone number, and any other point of contact at each visit.
Payment in full is due upon receipt of the statement. Patient balances not paid in full within 90 days of the statement issue date are deemed past due. If the patient account is past due for an amount more than $200 (two hundred dollars), the patient will not receive services from any medical providers at Denton Family Clinic and can be dismissed from the practice. Failure to accept the certified letter (and/or to pick it up at the post office) ser ves as notice of termination of services.
We do understand that temporary financial problems may affect timely payments. We encourage you to communicate any such problems and ask about our “Agreement to Pay for Physician Services” Plan.
In the event you submit payment by check and the bank returns the check unpaid for any reason, we will add $35.00 to your original balance. In addition, we may seek all additional legal remedies provided to us under Texas law.
The patient will be charged a “No Show” fee of $30 if they fail to cancel or reschedule the appointment at least 24 hours prior.

By signing this, you are agreeing to the clear understanding of our financial policy and how it is important to the relationship with Denton Family Clinic.

Patient’s Printed Name:	DOB:

COMMUNICATION PREFERENCES

I wish to be contacted in the following manner: (please list phone number and/or email that is best for staff to reach you)

Please select one option:

I authorize Denton Family Clinic to contant me using the phone number/email address provided above.

PATIENT AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION TO OTHERS

I authorize Denton Family Clinic to disclose or provide my protected health information to the following individual(s). This authorization will remain in effect until terminated by you, or the individual(s) of legal entity authorized to do so by court order or law.

You have the right to modify or revoke this authorization by submitting a written request to our office.

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Who Presents this Notice

This Notice describes the privacy practices of Denton Family Clinic and members of its workforce, as well as the physician
members of the medical staff and allied health professionals who practice at the Practice. The Practice and the individual health
care providers together are sometimes called “the Practice and Health Professionals” in this Notice. While the Practice and Health Professionals engage in many joint activities and provide services in a clinically integrated care setting, the Practice and Health Professionals each are separate legal entities. This Notice applies to services furnished to you at the Practice as a Practice patient or any other services provided to you in a Practice-affiliated program involving the use or disclosure of your health information.

Privacy Obligations

The Practice and Health Professionals each are required by law to maintain the privacy of your health information (“Protected
Health Information” or “PHI”) and to provide you with this Notice of legal duties and privacy practices with respect to your
Protected Health Information. The Practice and Health Professionals use computerized systems that may subject your Protected
Health Information to electronic disclosure for purposes of treatment, payment and/or health care operations as described below. When the Practice and Health Professionals use or disclose your Protected Health Information, the Practice and Health
Professionals are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

Permissible Uses and Disclosures Without Your Written Authorization

In certain situations your written authorization must be obtained in order to use and/or disclose your PHI. However, the Practice and Health Professionals do not need any type of authorization from you for the following uses and
disclosures:

Uses and Disclosures for Treatment, Payment and Health Care Operations. Your PHI, may be used and disclosed to treat you,
obtain payment for services provided to you and conduct health care operations” as detailed below:

Treatment. Your PHI may be used and disclosed to provide treatment and other services to you–for example, to diagnose and treat your injury or illness. In addition, you may be contacted to provide you appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Your PHI may also be disclosed to other providers involved in your treatment. For example, a doctor treating you for a broken leg may need to know if you have diabetes because if you do, this may impact your recovery.
Payment. Your PHI may be used and disclosed to obtain payment for services provided to you–for example, disclosures to claim and obtain payment from your health insurer, HMO, or other company that arranges or pays the cost of some or all of your health care (“Your Payor”) to verify that Your Payor will pay for health care. The physician who reads your x-ray may
need to bill you of your Payor for reading of your x-ray therefore your billing information may be shared with the physician
who read your x-ray.
Health Care Operations. Your PHI may be used and disclosed for health care operations, which include internal
administration and planning and various activities that improve the quality and cost effectiveness of the care delivered to you. For example, PHI may be used to evaluate the quality and competence of physicians, nurses and other health care workers. PHI may be disclosed to the Practice Compliance & Privacy Office in order to resolve any complaints you may have and ensure that you have a comfortable visit. Your PHI may be provided to various governmental or accreditation entities such as the Joint Commission on Accreditation of Healthcare Organizations to maintain our license and accreditation. In addition, PHI may be shared with business associates who perform treatment, payment and health care operations services on behalf of the Practice and Health Professionals.

Use or Disclosure for Directory of Individuals in the Practice. The Practice may include your name, location in the Practice, general health condition and religious affiliation in a patient directory without obtaining your authorization unless you object to inclusion in the directory. Information in the directory may be disclosed to anyone who asks for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or minister, even if they do not ask for you by name. If you do not wish to be included in the facility directory, you will be given an opportunity to object at the time of admission.

Disclosure to Relatives, Close Friends and Other Caregivers. Your PHI may be disclosed to a family member, other relative, a close personal friend or any other person identified by you who is involved in your health care or helps pay for your care. If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, the Practice and/or Health Professionals may exercise professional judgment to determine whether a disclosure is in your best interests. If information is disclosed to a family member, other relative or a close personal friend, the Practice and/or Health Professionals would disclose only information believed to be directly relevant to the person’s involvement with your health care or payment related to your health care. Your PHI also may be disclosed in order to notify (or assist in notifying) such persons of your location or general condition.

Public Health Activities. Your PHI may be disclosed for the following public health activities: (1) to report health information to public health authorities for the purpose of preventing or controlling disease, injury or disability; (2) to report child abuse and neglect to public health authorities or other government authorities authorized by law to receive such reports; (3) to report information about products and services under the jurisdiction of the U.S. Food and Drug Administration; (4) to alert a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition; and (5) to report information to your employer as required under laws addressing work-related illnesses and injuries or workplace medical surveillance.

Victims of Abuse, Neglect or Domestic Violence. Your PHI may be disclosed to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence if there is a reasonable belief that you are a victim of abuse, neglect or domestic violence.

Health Oversight Activities. Your PHI may be disclosed to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.

Judicial and Administrative Proceedings. Your PHI may be disclosed in the course of a judicial or administrative proceeding in response to a legal order or other lawful process.

Law Enforcement Officials. Your PHI may be disclosed to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.For example, your PHI may be disclosed to identify or locate a suspect, fugitive, material witness, or missing person or to report a crime or criminal conduct at the facility.

Correctional Institution. You PHI may be disclosed to a correctional institution if you are an inmate in a correctional institution and if the correctional institution or law enforcement authority makes certain requests to us.

Business Associates. Your PHI may be disclosed to business associates or third parties that the Practice and Health Professionals have contracted with to perform agreed upon services.

Decedents. Your PHI may be disclosed to a coroner or medical examiner as authorized by law.

Organ and Tissue Procurement. Your PHI may be disclosed to organizations that facilitate organ, eye or tissue procurement, banking or transplantation.

Research. Your PHI may be used or disclosed without your consent or authorization if an Institutional Review Board approves a waiver of authorization for disclosure.

Health or Safety. Your PHI may be used or disclosed to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.

Specialized Government Functions. Your PHI may be disclosed to units of the government with special functions, such as the U.S. military, the U.S. Department of State under certain circumstances such as the Secret Service or NSA to protect, for example, the country or the President.

Workers’ Compensation. Your PHI may be disclosed as authorized by and to the extent necessary to comply with state law relating to workers’ compensation or other similar programs.

As Required by Law. Your PHI may be used and disclosed when required to do so by any other law not already referred to in the preceding categories; such as required by the FDA, to monitor the safety of a medical device.

Appointment Reminders. Your PHI may be used to tell or remind you about appointments.

Fundraising. Your PHI may be used to contact you as a part of fundraising efforts, unless you elect not to receive this type of
information.

USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION

Use or Disclosure with Your Authorization. For any purpose other than the ones described above, your PHI may be used or disclosed only when you provide your written authorization on an authorization form (“Your Authorization”). For instance, you will need to execute an authorization form before your PHI can be sent to involve insurance company or to the attorney representing the other party in litigation in which you are

Marketing. Your written authorization (“Your Marketing Authorization”) also must be obtained prior to using your PHI to send you any marketing materials. (However, marketing materials can be provided to you in a face-to-face encounter without obtaining Your Marketing Authorization. The Practice and/or Health Professionals are also permitted to give you a promotional gift of nominal value, if they so choose, without obtaining Your Marketing Authorization). The Practice and/or Health Professionals may communicate with you in a face-to-face encounter about products or services relating to your treatment, case management or care coordination, or alternative treatments, therapies, providers or care settings without Your Marketing Authorization.

In addition, the Practice and/or Health Professionals may send you treatment communications, unless you elect not to receive this type of communication, for which the Practice and/or Health Professionals may receive financial remuneration.

Sale of PHI. The Practice and Health Professionals will not disclose your PHI without your authorization in exchange for direct or indirect payment except in limited circumstances permitted by law. These circumstances include public health activities; research; treatment of the individual; sale, transfer, merger or consolidation of the Practice; services provided by a business associate, pursuant to a business associate agreement; providing an individual with a copy of their PHI; and other purposes deemed necessary and appropriate by the U.S. Department of Health and Human Services (HHS).

Uses and Disclosures of Your Highly Confidential Information. In addition, federal and state law require special privacy protections for certain highly confidential information about you (“Highly Confidential Information”), including the subset of your PHI that: (1) is maintained in psychotherapy notes; (2) is about mental illness, mental retardation and developmental disabilities; (3) is about alcohol or drug abuse or addiction; (4) is about HIV/AIDS testing, diagnosis or treatment; (5) is about communicable diseases), including venereal disease(s); (6) is about genetic testing; (7) is about child abuse and neglect; (8) is about domestic abuse of an adult; or (9) is about sexual assault. In order for your Highly Confidential Information to be disclosed for a purpose other than those permitted by law, your written authorization is required.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Right to Request Additional Restrictions. You may request restrictions on the use and disclosure of your PHI (1) for treatment, payment and health care operations, (2) to individuals (such as a family member, other relative, close personal friend or any other person identified by you) involved with your care or with payment related to your care, or (3) to notify or assist in the notification of such individuals regarding your location and general condition. While all requests for additional restrictions will be carefully considered, the Practice and Health Professionals are not required to agree to these requested restrictions.

You may also request to restrict disclosures of your PHI to your health plan for payment and healthcare operations purposes (and not for treatment) if the disclosure pertains to a healthcare item or service for which you paid out-of-pocket in full. The Practice and Health Professionals must agree to abide by the restriction to your health plan EXCEPT when the disclosure is required by law.

If you wish to request additional restrictions, please obtain a request form from the Practice and submit the completed form to the Practice. A written response will be sent to you.

Right to Receive Confidential Communications. You may request, and the Practice and Health Professionals will accommodate, any reasonable written request for you to receive your PHI by alternative means of communication or at alternative locations.

Right to Revoke Your Authorization. You may revoke Your Authorization, Your Marketing Authorization or any written authorization obtained in connection with your PHI, except to the extent that the Practice and/or Health Professionals have taken action in reliance upon it, by delivering a written revocation statement to the Practice identified below.

Right to Inspect and Copy Your Health Information. You may request access to your medical record file and billing records maintained by the Practice and Health Professionals in order to inspect and request copies of the records. Under limited circumstances, you may be denied access to a portion of your records. If you desire access to your records, please obtain a record request form from the Practice and submit the completed form to the Practice. If you request copies of paper records, you will be charged in accordance with federal and state law. To the extent the request for records includes portions of records which are not in paper form (e.g. x-ray films), you will be charge the reasonable cost of the copies. You also will be charged for the postage costs, if you request that the copies be mailed to you. However, you will not be charged for copies that are requested in order to make or complete an application for a federal or state disability benefits program.

Right to Amend Your Records. You have the right to request that PHI maintained in your medical record file or billing records be amended. If you desire to amend your records, please obtain an amendment request form from the Practice and submit the completed form to the Practice. Your request will be accommodated unless the Practice and/or Health Professionals believe that the information that would be amended is accurate and complete or other special circumstances apply.

Right to Receive an Accounting of Disclosures. Upon request, you may obtain an accounting of certain disclosures of your PHI made during any period of time prior to the date of your request provided such period does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003. If you request an accounting more than once during a twelve (12) month period, you will be charged for the accounting statement.

Right to Receive Paper Copy of this Notice. Upon request, you may obtain a paper copy of this Notice, even if you have agreed to receive such notice electronically.

For Further Information or Complaints. If you desire further information about your privacy rights, are concerned that your privacy rights have been violated or disagree with a decision made about access to your PHI, you may contact the Practice Compliance & Privacy Office. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Practice Compliance & Privacy Office will provide you with the
correct address for the Director. The Practice and Health Professionals will not retaliate against you if you file a complaint with the Practice Privacy Office or the Director.

Effective Date and Duration of This Notice

Effective Date. This Notice is effective on May 26, 2025.

Right to Change Terms of this Notice. The terms of this Notice may be changed at any time. If this Notice is changed, the new notice terms may be made effective for all PHI that the Practice and Health Professionals maintain, including any information created or received prior to issuing the new notice.

PRACTICE CONTACTS:

Denton Family Clinic

E-mail: contact@dentonfamilyclinic.com

Phone: (682) 558-0342

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have been given the opportunity to receive the Notice of Privacy Practices. This notice identifies how certain medical information about you may be disclosed. I understand Denton Family Clinic reserves the right to change their Notice of Privacy Practices and prior to implementation will provide an updated copy on the clinic website and in the physician’s office.

Patient’s Printed Name:	DOB:

HIPAA INFORMATION and CONSENT FORM

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003.

By signing this document you are granting consent for Ndifreke Itata, APRN-C and all other supporting staff the authority to access any health records or medication history necessary to treat any conditions. You are consenting Denton Family Clinic to assessments and treatments necessary to treat you or clients under your guardianship. You are consenting to electronic communication (email, text, and telephone) reminders unless specified otherwise. Patients) understands all additional visits, additional documentation (FMLA), collaboration with other providers, or telehealth communications are a billable services. Patients are ultimately responsible for all balances.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected
Health Information (PHI). These restrictions do not include the normal interchange of information necessary to
provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance
these needs with our goal of providing you with quality professional service and care. Additional information is
available from the U.S. Department of Health and Human Services. www.hhs.gov (http://www.hhs.gov/)

We have adopted the following policies:

It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of the both the practice and the patient.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your

Disease	Notes
Diabetes
High Blood Pressure
Cancer
Stroke
COPD
High Cholesterol
GERD
Arthritis
Gout
Sleep Apnea
Asthma
Thyroid Disorder
Allergic Rhinitis
Other

Use of Alcohol:	Use of Tobacco:	Use of Illegal Drugs:
Marital Status:	Occupation:

Father:
Age:	Diseases:	If Deceased, Cause of Death:
Mother:
Age:	Diseases:	If Deceased, Cause of Death:
Grandparents:
Age:	Diseases:	If Deceased, Cause of Death:
Age:	Diseases:	If Deceased, Cause of Death:
Age:	Diseases:	If Deceased, Cause of Death
Age:	Diseases:	If Deceased, Cause of Death:

CONSTITUTIONAL:	GENITOURINARY:	HEENT:
INTEGUMENTARY (SKIN):	RESPIRATORY:	NEUROLOGICAL:
CARDIOVASCULAR:	PSYCHIATRIC:	GASTROINTESTINAL:
MUSCULOSKELETAL:

Bone Density:
Date Performed:	Normal or Abnormal?:
Colonoscopy:
Date Performed:	Normal or Abnormal?:
Foot Exam:
Date Performed:	Normal or Abnormal?:
Echocardiogram:
Date Performed:	Normal or Abnormal?:
Endoscopy:
Date Performed:	Normal or Abnormal?:
EKG:
Date Performed:	Normal or Abnormal?:
Spirometry:
Date Performed:	Normal or Abnormal?:
Stress Test:
Date Performed:	Normal or Abnormal?: