Topanga Medical — Patient Intake

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Patient Information

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Subscriber Information

SUBSCRIBER'S NAME (If different from above)

DATE OF BIRTH

SOCIAL SECURITY #

SUBSCRIBER'S EMPLOYER

OCCUPATION

EMPLOYER'S ADDRESS

CITY

STATE

ZIP

WORK PHONE #

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HOW LONG EMPLOYED?

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Insurance

PRIMARY INSURANCE - NAME OF INSURANCE PLAN

PRIMARY INSURANCE - DOB

PRIMARY INSURANCE - ID#

PRIMARY INSURANCE - NAME OF SUBSCRIBER

PRIMARY INSURANCE - SUBSCRIBER ID#

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Emergency Contact & Referral

IN AN EMERGENCY, CONTACT

EMERGENCY CONTACT PHONE#

Emergency Contact Phone Type

CELLHOMEWORK

WHO REFERRED YOU TO OUR DOCTOR?

YOUR PRIMARY CARE PHYSICIAN IS

PRIMARY CARE PHYSICIAN PHONE #

Primary Care Physician Phone Type

CELLHOMEWORK

REASON FOR TODAY'S VISIT

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Assignment of Benefits

I HEREBY ASSIGN THE BENEFITS DUE ME THROUGH MY INSURANCE CARRIER TO SOCAL GASTROENTEROLOGY FOR SERVICES RENDERED. I ALSO AUTHORIZE AND INSTRUCT MY INSURANCE CARRIER TO MAKE PAYMENTS OF AUTHORIZED BENEFITS TO SOCAL GASTROENTEROLOGY. I UNDERSTAND THAT I AM FULLY RESPONSIBLE FOR ALL CHARGES NOT PAID BY THE INSURANCE COMPANY, I AUTHORIZE RELEASE OF ALL MEDICAL INFORMATION REQUIRED TO PROCESS THIS CLAIM.

SIGNATURE OF PARENT OR RESPONSIBLE PARTY*

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By signing above you confirm the information provided is accurate to the best of your knowledge. Signed electronically on September 12, 2026.

DATE

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Visit Details

Patient Name

DOB

Today's Date✓ From EHR

Pharmacy Name/Address/Phone#

Reason for your visit today

Medications: incl. Over-The-Counter meds (Name / Dosage / Frequency)

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Allergies: (include reactions)

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Height

Weight

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Past Medical History

Check box if you have ever had:

GI & General Past Medical History

Condition

Year

Yes/No

Last Colonoscopy

Other

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Surgical History

Check box if you have ever had:

GI, OB/GYN, General and Orthopedic Surgery History

Procedure

Yes/No

Other

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Family History

Condition

Member & Age

Yes/No

Other

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Social History

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Signature

SIGNATURE OF PARENT OR RESPONSIBLE PARTY*

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By signing above you confirm the information provided is accurate to the best of your knowledge. Signed electronically on September 12, 2026.

DATE

I confirm that the information on this form is accurate and authorize Rempli to share it with my healthcare provider. I understand my EHR data was accessed using my patient portal login and may be stored by Rempli to pre-fill future forms.