rockvilleobgyn.com - New Patient Form

Dear Patient:

It is with pleasure that we welcome you to Capital Women’s Care. To help your visit go as smoothly as possible, please assist us by bringing the following with you:
- This form must be completed and signed before the day of your appointment. If not completed your appointment will need to be rescheduled.
- Current insurance card(s) and Drivers License or Photo ID must be presented upon arrival.
- Insurance referral form, if necessary.
- Co-payments are collected upon arrival. We accept cash, check, American Express, Visa, MasterCard, and Discover. If you are unable to make your payment, your appointment will need to be rescheduled.
- Please arrive 20 minutes before your scheduled appointment time to complete the necessary registration information.
- Missed Appointment Policy: We respectfully request that you cancel your scheduled appointment by phone 24 hours in advance. If you do not cancel by the deadline, you may be assessed a $50.00 missed appointment fee. This fee is not covered by insurance carriers and it will be your responsibility to pay. Our aim here is to open otherwise unused appointments for our patients, not to collect missed appointment fees. Your cooperation and consideration is appreciated.
Important Reminders
- Capital Women’s Care is located in 9711 Medical Center Drive Suite 109, Rockville, MD 20850.
- We participate with many insurance companies. Please confirm the participation of our providers with your insurance company. If your insurance company requires a referral it is your responsibility to obtain the referral. The referral must be presented at the time of your appointment. This office cannot provide treatment if the required referral has not been obtained. If you do not have your insurance referral form at the time of your appointment we reserve the right to cancel and reschedule your appointment or you may pay in full at the time of service.
- Please notify our office if there are any changes to the following information: Home Address, Telephone Number(s), Insurance Information.
- The charge for the completion of forms is $20.00. Forms will be completed within two weeks.
My appointment is scheduled on:
Date*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Doctor*
This form needs to be completed in its entirety prior to your visit.

Medical History

Please complete all fields prior to your appointment and submit them electronically. All fields are required. Please enter "N/A" if the question does not apply.
Today's Date*

MonthDayYear
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
Email*
example@example.com
Pharmacy Name*
Pharmacy Phone Number*
Pharmacy Address

Street Address

Street Address Line 2

CityState

Zip Code

Insurance Information
Policy Holder Name*

First NameLast Name
Policy Holder DOB*

MonthDayYear
Date
Insurance Effective Date

MonthDayYear
Date
Policy #*
Group #*

Patient Information
Employer
Occupation
Level of Education
Do you have a spouse or partner?

YesNoPrefer not to say
Name of Spouse/Partner
Spouse/Partner Contact Number
Who referred you to our practice
Primary Care Physician*
Current Medications or Vitamins*
Allergies*

	Mother	Father	Sister	Brother	Children	Unknown
Alive and Well
Deceased (Cause)
Alcoholism
Autoimmune Disease
Birth Defects
Bleeding Disorder
Blood Clots
Breast Cancer
Colon Cancer
Depression
Developmental Delay
Genetic Disease
High Cholesterol
High Blood Pressure
Kidney Disease
Mental Illness
Osteoporosis
Ovarian Cancer
Seizure Disorder
Sickle Cell Anemia
Thyroid Disease
Uterine Cancer

	Date	Sex	Weight	Labor Hours	Anesthesia	Complications
Pregnancy 1
Pregnancy 2
Pregnancy 3
Pregnancy 4
Pregnancy 5
Pregnancy 6

	You	Your Family	Partner	Partner's family	Unknown
Learning Disorders
Birth Defects
Cardiac Disease
Ashkenazi Jewish
Fragile X
Autism
Sickle Cell Disease
Alpha Thalassemia
Inherited/Genetic Disorder

My appointment is scheduled on:

This form needs to be completed in its entirety prior to your visit.

Medical History

Insurance Information

Patient Information

Gynecological History

Surgical History

Family Health History

Obstetrical History