Todays Date * Your Name * E-mail Address: * Age * Date of Birth * Sex * Marital Status * Address * City * State * Zip Code * Home Phone * Cell or Business Phone * Employer * Occupation * Employer Address * City * State * Zip Code * Insurance Card Holder Name * Insured Date of Birth * Insured Address * Insured City * Insured State * Insured Zip Code * Insured Home Phone * Insured Business Phone * Insured Employer * Insured Occupation * Insured Employer Address * Insured Employer City * Insured Employer State * Insured Employer Zip Code * Referred to our office by: * Insurance Company * Policy Number * Group Number * Effective Date * Other Medical Coverage Type * Other Medical Coverage ID Number * Name of Emergency Contact Person * Phone Number of Emergency Contact * Why are you being seen in our office today? Date of Last Menstrual Period Do you use a method of contraception? YesNo If yes, what type? Has there been a change in your periods? YesNo If yes, explain Do your periods cause you problems? YesNo If yes, explain Do you experience menopausal symptoms? YesNo If yes, explain Date of last PAP smear Result of PAP Smear Date of last mammogram Result of last mammogram Do you have breast changes or pain? YesNo Are you physically or emotionally abused? YesNo Do you have sexual problems? YesNo If yes, explain Do you smoke cigarettes? YesNo How Much/How Often? Do you drink alcohol? YesNo How much/How often Do you exercise? YesNo How much/How often Do you use recreational or street drugs? YesNo What/How often Do you have a primary care physician? YesNo If yes, who is your primary care physician? Are you currently taking any medications? YesNo List Drug name and dosage Do you have any drug allergies? YesNo If yes, please list List any serious illnesses that you have List any surgeries that you have had Have you had any of the following? Frequent, severe headaches Back/joint pain Chest pain Skin problems Urinary problems Bowel problems Abdominal pain Unintentional weight changes Eating disorders Excessive fatigue Anxiety/depression Is there any other information we should have about your health? What is the date of your appointment? Verification Code: Enter Verification Code: * * Required

Assignment of Benefits
Providing quality medical care for our patients is our primary concern. We are more than willing to provide that care within your insurance guidelines. If you let us know at each time of service exactly what those guidelines are. Unfortunately, if you do not inform us of any special requirement in your contract and we subsequently order services, such as lab work, x-rays, or hospitalization, that are not covered, we or the selected medical facility will have no choice but to bill you directly for those charges. Payment for those charges is then your responsibility. As the policy holder, YOU ARE RESPONSIBLE for knowing the benefits and restrictions of your insurance coverage.

WAIVER: I understand that should my insurance company require a REFERRAL/AUTHORIZATION prior to my receiving medical services and I have not obtained this and/or this office has not received this, I WILL BE RESPONSIBLE FOR ALL CHARGES INCURRED.

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