Patient Registration Form

Welcome to EI Camino GI Medical Associates!! Please complete this form in full, leaving no blanks. If anything does not apply, please indicate so. Then read and sign the last portion.
  • Date Format: MM slash DD slash YYYY
  • (Please indicate which contact number/email confidential communications may be relayed.)
  • Date Format: MM slash DD slash YYYY
  • Name of friend or relative that we may contact in case of emergency:
  • Date Format: MM slash DD slash YYYY
  • I, the undersigned, understand the payment policies of this office and understand that I am financially responsible to the treating physician for all charges incurred regardless of insurance coverage. If the amount due is not paid, I agree to bear collection costs, court costs, and legal fees.
  • This field is for validation purposes and should be left unchanged.