TRI-CITY COLO-RECTAL SURGERY, LTD.
K.S. Venkatesh, MD, FRCS (C), FACS, FASCRS Robert A. Campbell, MD, FACS, FASCRS
Krishna A. Venkatesh, MD, FACS, FASCRS Hekmat Hakiman, MD, FACS, FASCRS Arpit Patel, MD, FACS, FASCRS
2223 East Baseline Road, Suite A
Gilbert, Arizona 85234
Phone (480) 835-5302 Fax (480) 844-2081
Date: _____________________ Referred by: _________________________ Primary Care Doctor: ___________________
Patient Name: ___________________________________________________________ SS#: ______ / ______ / ______
First Initial Last
DOB: _____ / _____ / _____ Age: ______ Male / Female Race: _______________ Ethnicity: ____________________
(circle one) Primary Language: ___________________________
Address: ______________________________________________ City: ___________________ State: ______ Zip: _________
Home Phone: (_____) ______________ Cell Phone: (_____) ______________ Work Phone: (_____) _______________ /_____
ext
Your Employer: ___________________________________ Address: ______________________________________________
PHARMACY NAME: _____________________________ PHARM PHONE: (_____) _______________ PHARM ZIP: ________
Spouse Name: ___________________________________________________________ DOB: _____ / _____ / _____
First Initial Last
Spouse Employer: __________________________________ Address: ____________________________________________
Spouse SS#: ______ / ______ / ______ Work Phone: (_____) _______________ /_____ Alternate: (_____) _______________
ext
EMERGENCY CONTACT: _____________________________ DOB: ____ / ____ / ____ RELATIONSHIP: _______________
PHONE: (_____) ______________ ALTERNATE PHONE: (_____) ______________
If Patient is a Minor:
Parent Name: ____________________________________________________________ DOB: _____ / _____ / _____
First Initial Last
Address: ______________________________________________ City: ___________________ State: ______ Zip: _________
Parent Employer: __________________________________ Address: _____________________________________________
Parent SS#: ______ / ______ / ______ Home Phone: (_____) ________________ Work Phone: (_____) _________________
INSURANCE INFORMATION
Primary: _____________________________________ Secondary: __________________________________
Address: _____________________________________ Address: ____________________________________
____________________________________________ ____________________________________________
Phone: (________) ____________________________ Phone: (________) ____________________________
ID#: __________________ Group #: ______________ ID#: __________________ Group #: ______________
Insured Name: ________________________________ Insured Name: _______________________________
NOTE: If your insurance requires a referral or authorization for office visits, it is your responsibility to obtain this prior to your visit.
I authorize the release of medical information necessary to process insurance claims. I authorize payment of the medical benefits to Tri-City
Colo-Rectal Surgery, Ltd. for the services rendered. I understand that I am responsible for any charges or balance not covered by my
insurance carrier.
Patient Signature: ________________________________________________________ Date: ____________________
Lifetime Signature
Parent or Guardian Signature: ______________________________________________ Date: ____________________
Lifetime Signature
