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New Patients Form

WELCOME and thank you for choosing our practice.

Please bring your current insurance card(s) with you so that we can file your insurance claim. The information on your insurance card plays a critical role in our ability to bill your insurance company for your visit. If you do not have your insurance card, we ask that you either reschedule your appointment or pay for your visit in full at the time services are rendered. Upon request, we can mail an itemized statement to you so that you can submit your claim to your insurance company. If we do not participate with your insurance plan, payment is required at the time of service.

Patient financial responsibility includes any copays, additional testing, and services not covered by your insurance. We accept cash, personal checks drawn on a local bank, American Express, Visa, MasterCard and Discover.

Lab tests such as blood work, Pap smears, etc., are billed separately by the laboratory and are not included in our fees.

We ask that you arrive 15 minutes prior to your scheduled appointment time. If for any reason you are unable to keep your appointment, please call the office to cancel or reschedule at least 24 hours in advance to avoid cancellation fees.

Before your appointment, please arrange to have sent to our office any medical records from any previous physician that may be appropriate to your gynecological care with us. You may use the form "Request medical records from another physician to be sent to Premier Care" on our website home page.

There is a parking garage on the premises for your convenience. However, we cannot validate the parking tickets. Please bring $6.00 for the parking fee. Credit/debit cards are not accepted, cash or check only.

We look forward to seeing you!

PATIENT INFORMATION:

LAST NAME: *
FIRST NAME: *
MI:

REFERRING DOCTOR:

BIRTHDATE: / / *
SEX (M / F):
PRIMARY CARE PHYSICIAN:
MARITAL STATUS

INSURED PARTY INFORMATION:

PRIMARY INSURANCE COMPANY NAME:
MAILING ADDRESS
PHONE #
POLICY #
GROUP #

If you are NOT the primary insurance holder, please complete the following:

LAST NAME:
FIRST NAME: MI:
BIRTHDATE: / /
SEX (M / F):
RELATIONSHIP TO PATIENT:

SECONDARY INSURANCE COMPANY NAME:
MAILING ADDRESS
PHONE #
POLICY #
GROUP #


PATIENT MEDICAL INFORMATION:

Which doctor are you seeing?
Appointment Date: / /
Are you new to this practice? Yes No
Full Name:
DOB: / / Age:
Today's Date: / /
e-mail:
Emergency Contact:
Reason for Today's Visit:
Pharmacy Name:
Pharmacy Phone:
Pharmacy City/State:

ALLERGIES:
Drug: Food:
Latex Allergy: Yes No

MEDICATIONS: (List all current medications that you are taking, including vitamins and herbal supplements)
DRUG / DOSAGEFREQUENCY / TAKEN



OBSTETRICAL HISTORY: (Please list all past pregnancies and their outcomes)
*NEVER been pregnant, please check

(Date of Delivery (M/D/Y) / Type(Vaginal, C-section, miscarriage, abortion) / Baby Weight / Doctor Complications)

SURGICAL HISTORY / SERIOUS ACCIDENTS / HOSPITALIZATIONS:
*If NONE please check

Date / Operation or Illness / Doctor / Hospital / Complications

FAMILY HISTORY: List any 1st DEGREE relatives (Mother/father/siblings/children) who have or have had any of the following:
Unknown / Adopted
Endometriosis
Uterine fibroids
Heart attack
High blood pressure
Blood Clots
Stroke
Diabetes
Osteoporosis
other

Cancers:
Breast
Ovarian
Colon
Melanoma
other

MEDICAL HISTORY: (Have you been diagnosed with any of the following illnesses? If so note YEAR of diagnosis)

Illness: Yes No Date
GYNECOLOGICAL:
Sexually Transmitted Dz:
If YES, please select: Chlamydia herpes genital warts Gonorrhea
syphilis trichomonas
Vaginal Infections:
If YES, please select: bacterial infection yeast infection
Endometriosis
Uterine Fibroids
CARDIOVASCULAR:
Heart Murmur
Heart Attack
Heart Defect
Heart Palpitations
High Blood Pressure
High Cholesterol
Thrombophlebitis
CONGENITAL:
Hereditary Defects
DIGESTIVE:
Colonoscopy Scan
Diverticulosis
Reflux
Stomach Ulcers
Irritable Bowel
ENDOCRINE:
Diabetes
Thyroid Disease
Anemia
Liver Disease
HEMATOLOGICAL:
Bleeding Tendencies
Blood Clots
MUSCULOSKELETAL:
Bone Density Scan
Osteoporosis
Osteopenia
NEOPLASM:
Cancer/Type
NEUROLOGICAL:
Convulsions / Seizures
Migraines
Stroke
PSYCHIATRY:
Mental Illness
If yes, diagnosis
RESPIRATORY:
Asthma
Pneumonia
Tuberculosis
Rheumatic Fever
SIGNS/SYMPTOMS:
Glaucoma
UROLOGY:
Bladder Leakage
Frequent Bladder Infections
Kidney Infections
Kidney Disease
Kidney Stones
Other:

 

GYNECOLOGIC HISTORY:
First day of last menstrual period / /
Usual # of days from one period to the next?
How many days do your periods last?
Are your periods: Heavy with clots Med Light
Cramps or pain with periods? Yes No
Excessive bleeding? Yes No
Spotting between periods? Yes No
Are you sexually active?
At what age?
Do you use condoms to prevent STDs? Yes No
What are you doing to prevent pregnancy? Birth control pill
Condoms IUD Diaphram Vasectomy tubal ligation
other (please explain)

Gender of sexual partners: M and/or F

Age at menopause:
Taking Hormones: Yes No
Have you taken hormones in the past? Yes No
How long?
Last Pelvic Exam / /
Last pap smear / /
Have you EVER had an abnormal pap smear? Yes No
If yes, how was it treated?
Have you ever been diagnosed with HPV? Yes No
Number of HPV/Gardasil injections: none 1 2 3

When was your last mammogram? / /
Have you EVER had an abnormal mammogram? Yes No
If so, how was it treated?
Have you ever been a victim of sexual abuse? Yes No
Physical Sexual

 

Our practice appreciates the diversity of women and does not discriminate on the basis of race, age, religion, ability, marital status, sexual orientation, or perceived gender. If you would like to discuss sexual issues with the doctor, do not hesitate.

SOCIAL HISTORY:
Single Engaged Married Life partner Separated Divorced Widow Lesbian

School completed:
High School 2 YR College 4 YR College Grad School

Occupation:

Exercise weekly? 0 – 1 2 – 3 more than 4

Use of alcohol? Never Rarely Moderate Daily

Use of recreational drugs? Never Previous Current
Drug used

Use of tobacco: Never Previous Current:
(# per day #Yrs )

Have you ever had a transfusion? Yes No

Have you ever been a victim of domestic violence Yes No
Physical Emotional

REVIEW OF SYSTEMS: (Please CHECK any symptoms you currently have)
CONST: Fatigue chills, body aches, recent weight loss,
recent weight gain, fever, chills, night sweats
EYES: Impaired vision, Blurred vision
ENT: Frequent headaches
BREASTS: Lumps, swelling, tenderness, nipple discharge
CARDIO: Chest pains, rapid heart rate or irregular heart beats
RESP: Shortness of breath, cough, wheezing
GI: Nausea, vomiting, constipation, diarrhea, abdominal pain, blood in stools, loss of appetite, hemorrhoids
GU: Urgent or frequent urination, blood in urine, painful intercourse, vaginal discharge, genital sores
INTEGUMENT: Rash, new or growing moles, excessive hair growth, acne
NEURO: Muscular weakness, numbness, memory difficulties
MUSC: Joint pain, muscle pain, muscular weakness, back pain
ENDO: Heat or cold intolerance, excessive thirst, loss of hair
PSYCH: Anxiety, depression, difficulty sleeping
HEME/LYMPH: Easy bruising, easy bleeding


PAYMENT GUARANTEE

First and Last Name:

If we participate in your insurance plan and provided you present your insurance card at time of service, we will collect your copayment and any other charge for services that we know are not covered by your insurance. We accept cash, check or credit card. The remainder of your charges today will be billed to your insurance company. Please follow up with your insurance company to ensure your claim is paid timely. Claims not paid by your insurance company within 60 days become patient responsibility. If you do not have insurance in which we participate or do not have your insurance card, all fees are due and payable at time of service.

We test for HPV on all women, with a cervix, over 30 years of age every three (3) years, which is the standard of care set forth by the American College of OB/GYN.

***I hereby certify that all insurance information provided is true and accurate and that I am responsible for keeping it updated. I hereby authorize Premier Care for Women to submit claims on my behalf to my insurance company and to accept payment from my insurance company on my behalf. I understand that the submission of a claim does not absolve me of my responsibility to ensure the claim is paid in full and that I may be responsible for any and all amounts not payable by my insurance company including non covered services, deductibles, coinsurance, services determined by the insurer as not medically necessary or any failure by my insurer to comply with all applicable laws. I authorize release of records to the insurance company as requested in order to facilitate claims payment.

I understand that rebilling fees of $10 per month are applied to my account if charges turned over to patient responsibility are not paid promptly and that failure to keep my account current may limit my access to the Practice and my physician until the balance has been paid in full or acceptable payment arrangements have been formalized. I understand that returned checks incur a fee of $25, must be repaid by cash or credit card including the $25 fee, and that Premier Care for Women may seek recovery using the means available to them under Georgia Law. I understand that Premier Care for Women utilizes the services of a collection agency as necessary. I further understand that access to the Practice and my physician may be limited if my account is sent to collections until the balance is paid. If I am sent to collections twice, I may be dismissed from the Practice. I have been made aware there is a $25 “No Show” Fee for all appointments not cancelled within 24 hours prior to the appointment.   Urogynecological appointments will incur a $50 fee if not cancelled within 24 hours prior to the appointment***

PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby give consent for Premier Care for Women to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). I have the right to review and request a copy of the Notice of Privacy Practices at any time.

With this consent, Premier Care for Women may leave voice mail messages, mail correspondence or e-mail to my home or other alternative location or number that I have provided for appointment reminders, patient statements,  insurance or clinical care items.  Contact regarding issues of a sensitive nature will be made by personal phone call or letter from a member of Premier Care for Women.

I understand that I have the right to request, in writing, that Premier Care for Women restrict how it uses or discloses by PHI to carry out TPO , but the Practice is not required to agree to my requested restrictions. If it does, it is bound by this agreement. I may revoke my consent in writing, except to the extent that the Practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Premier Care for Women may decline to provide treatment to me.

**You will be asked to sign this form at time of your appointment**

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