Online Patient Appointment & Consent Form

Online Patient Appointment & Consent Form
Please note if you have any type of insurance (Medicaid, Medicare, ObamaCare or etc) or are finiacially capable to afford to see a doctor, then Please Do Not Proceed to request an appointment.

This service is ONLY for those who do not have insurance and are not financially able to afford basic health services.

Our EHR system checks if you have insurance and if we discover that you do have insurance, then you will not be given an appointment and any existing appointments will be cancelled.
You are legally agreeing to the above statement and confirming by clicking "YES"*
Do you have Insurance?*
This service is ONLY for those who do not have insurance and are not financially able to afford basic health services.

We cannot make any appointment for you at our clinic.

Thank you.
Reason for Appointment*
Appointment Type*
Please note, all Gynecologist appointments are in-person at the clinic. We do not schedule prenatal appointments. If you are pregnant, please do not proceed with submitting this form.
Last Normal Menstrual Period (First Day)*
Length of Periods*
Length of Cycles*
Last Pap Smear-Date*

MonthDayYear
Date
Last Mammogram-Date*
Are you currently pregnant?*
Patient’s Full Name*

First NameLast Name
Gender:*
Date of Birth:*

MonthDayYear
DOB
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*

Area CodePhone Number
Alternate Number

Area CodePhone Number
Email:*
example@example.com
Marital Status?*
Emergency Contact Person
Full Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Preferred Pharmacy*
Name of Pharmacy
Pharmacy Phone Number*

Area CodePhone Number
Other (specify):
Notice of Privacy Practices, Release of Billing Information, Consent for Treatment and Assignment of Benefits.
I have read and understand the terms in the above document and agree to the eCommunications disclosure agreement and telemedicine services.*

CLICK HERE
Patient Full Name:*
First Name Middle Initial Last Name
Date:*

MonthDayYear
Date
Are you signing in for a minor?*
If patient is minor, please specify the relationship to the patient
Your Name:
First Name Middle Initial Last Name
Take a picture of a valid form of ID (driver license, passport, greencard, etc).*
Should be Empty:

Online Patient Appointment & Consent Form

Emergency Contact Person