New Patient Intake Forms The SHOW Center

Welcome to The SHOW Center

New Patient Paperwork
Thank you for choosing The Sexual Health Optimization and Wellness (SHOW) Center! Our licensed nurse practitioner, Dr. Heather Quaile welcomes you and she is excited to join you on your healthcare journey. After scheduling your first appointment, please fill out the information below. Please give yourself 10-15 minutes to fill out the forms. Please fill out all of the forms (including tele-health consent) even if you have an in-person appointment, as you may require a tele-health appointment in the future. After finishing this questionnaire click submit and your information will be reviewed prior to your appointment. Enclosed you will find information pertinent to your care with us. If you have any questions or concerns, please don’t hesitate to call or email.
Patient Information and Consents
Name *

Preferred Name Legal Last Name
DOB *
Preferred Pronouns:

She/Her/Hers Other They/Them/Theirs He/Him/His Other
Address *

Address

Street Address Line 2

City State

Zip
Email *
example@example.com
Mobile Number *
Please enter a valid phone number.
I give permission for the The SHOW Center to leave messages on my voicemail. *

Yes No Signature:
Signature *

Clear
Insurance Provider *
Race

African American Asian Caucasian Hispanic Native American Other
Ethnicity

Hispanic Non-Hispanic
Relationship status

Single Married Widowed Divorced Partnered Other
Name of Partner if Applicable *
NA if not applicable
Employment

Employed Unemployed Disabled Retired Student
Primary Care Provider *
Preferred Pharmacy *
Emergency Contact *

First Name Last Name
Emergency Contact Relationship *
Emergency Contact Number *
How did you here about The SHOW Center *
Was it a friend, please feel free to let us know who so we can thank them!
Welcome to The SHOW (Sexual Health Optimization and Wellness) Center, the office of nurse practitioner, Dr. Heather C. Quaile DNP, WHNP-BC, SANE. We are committed to delivering service, compassion and quality care to you. Understanding our Policies is an important part of our professional relationship.

NOTICE OF HIPAA PRIVACY PRACTICE

The following consent is required by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPPA). CONSENT FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) Protected Health Information or PHI is any information that is unique to you. It includes any personal information about you and your health care. I authorize the use and disclosure of my PHI for purposes of treatment, payment, and daily healthcare operations which include but are not limited to: the coordination of healthcare services between providers of such services; services with insurance companies regarding payment, reimbursement, premiums, eligibility, coverage, and utilization review; third party collectors and consumer reporting agencies. I have been offered a copy of the Notice of Privacy Practices. I understand that I may review the office’s Notice at any time. I understand the Notice may change and that I may request a revised Notice. I understand that I may request restrictions be placed on disclosure of my PHI, but The SHOW Center is not obligated to comply with my requests, unless they agree to my restrictions in writing. I understand that I have a right to revoke the consent, in writing, to the extent that The SHOW Center has not yet taken any action in reliance upon the consent.

The SHOW Center have always protected your personal information and we will continue to do so. If for any reason you are not willing or able to sign the consent, then we will be unable to enter into a provider/patient relationship with you.

(This authorization will remain in effect unless request is received by our office in writing. By signing this form, I authorize the release of my personal medical information to above persons)

Please list any persons whom you authorize us to discuss or release medical information and /or test results with (below):
Authorized Person

First Name Last Name
Date

Month Day Year
Date
List any specific instructions or limits for authorization:
By checking this box, I certify that no one is authorized to receive my medical information

I certify that no one is authorized to receive my medical information.
Signature *

Clear
Date *

Month Day Year
Date
CONSENT AND PRIVACY POLICY

Consent for Care:

I authorize The SHOW Center, and any employee working under the direction of The SHOW Center to provide healthcare for me. This medical care may include services such as: preventative services, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment of physical and/or mental status, recommendations for care, referral, prescriptions and follow up care.

Consent for Release of Information:

I authorize The SHOW Center to furnish my medical information to identified insurance carriers for any and all submissions for out of network claims. In the event that I desire my medical information to be sent elsewhere, I understand a separate consent form will need to be signed.

Financial Policy:

I understand that my fee covers the time and expertise of the providers at The SHOW Center. While every attempt will be made to treat my concerns, I understand that in some cases, referral is required. I understand that The SHOW Center is an out of network provider, this allows us to spend more time with you without the limitations placed by insurance plan, and the fee will be due in full at the time of the appointment. If you are unable to pay at the time of your visit, we will reschedule your visit. We accept most major credit cards and you can utilize your HSA or FSA account. Because we are an out of network provider your insurances may or may not cover the visit and the reimbursement may vary in coverage, and it is the patient's responsibility to understand medical benefits and requirements. We recommend that the patient verifies insurance benefits for any procedures, surgeries, tests or other services scheduled. You will be responsible for 100% of your total out of pocket responsibility amount prior to any procedures, visits, testing, or services. We do our best to estimate your financial responsibility up front, but please understand this is only an estimate. We will give you a super bill after your visit and will make every effort to address and code such things that are typically covered by most commercial insurance plans. However, given the nature of many topics discussed, some insurance companies may deny coverage, and therefore decline payment. We are an out of network provider and have been told you can expect reimbursement of 30%-80% of your bill. Because every plan varies, I understand it is my responsibility to verify applicable coverage prior to receiving services. These decisions are, unfortunately, out of our control. We are hopeful that this will change in the near future, and that insurance companies will realize that sexual health is an important part of overall health. We appreciate your trust in our care and your help in trying to make important changes in the ever shifting landscape of healthcare.

Privacy Policy:

The SHOW Center will not share my demographic or healthcare information with anyone except my insurance company, as noted above, or any other party unless another consent form giving this permission is signed. I understand that The SHOW Center will occasionally consult with other healthcare providers and in this case, they will not use any identifying information when presenting my case. I understand that the consultation is at the cost of The SHOW Center, and not myself, unless agreed otherwise. I understand that The SHOW Center will maintain my healthcare information in a secure electronic health record. I give permission to The SHOW Center to retrospectively evaluate my information in an anonymous fashion for possible publication of descriptive research. I understand that no research is currently being performed with me as a participant and another consent form would need to be completed if I desired to be involved in other research or clinical trials.

Communication about MY Healthcare:
I agree that the provider and/or agent of the provider or the clinic office may contact me for the purposes of scheduling necessary follow-up visits recommended by the treating provider.

Use of Electronic Medical Health Record:

This practice/clinic uses an electronic health record that will update all your demographics and consents to the information you provided. Please note that this information will also be updated for your convenience to all our affiliated locations that share an electronic health record in which you have a relationship. I authorize this practice/clinic to use their electronic health record to keep all of my health records at this time.

Use of ePrescribing via our Electronic Medical Health Record:

Our practice participates in ePrescribing via our electronic medical record (EMR) which has achieved Certification Commission for Health Information Technology (CCHIT) certification. Electronic prescriptions are submitted to the pharmacy designated by the patient.

Use of Telemedicine/Telehealth Services:

I authorize and agree that some services may involve the use of telemedicine or telehealth equipment and interaction with providers that are outside of my physical presence. I understand that I will be advised in advance of any such use of technology.

Consent for Photographing or Other Recording for Security and/or Health Care Operations:

I consent to photographs, digital or audio recordings, and/or images of me being recorded for patient care, security purposes and/or the practice/clinic’s health care operations purposes (e.g., quality improvement activities). I understand that the practice/clinic retains the ownership rights to the images and/or recordings. I will be allowed to request access to or have copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used outside the facility without a specific written authorization from me or my legal representative unless otherwise permitted or required by law.

Consent to Email, Cellular Telephone or Text usage for Appointment Reminders/Healthcare Communications:

If at any time I provide an email address or cellular phone number at which I may be contracted, I consent to receiving unsecure instructions and other healthcare communications at the email or text address I have proved or you or your EBO Servicer have obtained, at any text number forwarded, or transferred from that number.

These instructions may include, but not limited to: post-procedure instructions, follow-up instructions, educational information, and prescription information. Other healthcare communications may include but are not limited to, communications to family or designated representatives regarding my treatment or condition, or reminder messages to me regarding appointments for medical care. I understand that I may opt out of these communications at any time. The practice/clinic does not charge for this service, but standard text messaging rates or cellular phone minutes may apply as provided in your wireless plan.

Miscellaneous

In the unfortunate event that your account is turned over to our Collection Agency a 30% fee will be billed to your account.

Due to federal regulations, you must be able to provide your current insurance card (for lab work when necessary) at every appointment, along with a photo ID. Without these cards we will not be able to see you or you may be responsible for payment (of labs) at the time of service.If you are under the age of 18, your parent or guardian must provide these items. Please call with any insurance questions. We are not currently accepting any new patients with Medicaid and we are opted-out of Medicare plans.

We look forward to working with and thank you for entrusting us with your care.

I have read and understand the Consent, Policies, and Privacy Policy stated above, have had all of my questions answered and accept full responsibility as described above.

By signing below, I hereby agree to and understand the financial policy for The SHOW Center and give consent to the providers to treat my medical concerns and bill for professional services rendered.
Signature *

Clear
Date *

Month Day Year
Date
GENERAL CONSENT FOR CARE AND TREATMENT CONSENT

You have the right, as a patient, to be informed about your condition and the recommended surgical, medical, or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you are indicating that you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. You have the right to discuss the treatment plan with your healthcare provider about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommended by your health care provider, we encouraged you to ask questions. I voluntarily request a healthcare provider or designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s), procedure(s), or surgery(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. I understand that this authorization is valid for one calendar year, from the date listed on this form. I understand that if I refuse to sign, such refusal will result in the practice/clinic’s inability to provide healthcare to me today.
Signature *

Clear
Date *

Month Day Year
Date
CONSENT FOR OFF LABEL MEDICATION IF INDICATED

There are many medications that are FDA approved for safe and effective treatment for a particular indication (medical problem) or for a particular population (gender or menopausal status) that we prescribe for a different indication or a different population of patient. Examples of off label treatment would be a testosterone product that is FDA approved for men but is being prescribed for a woman in a different amount, or a medication like Addyi that is FDA approved for premenopausal women but is being prescribed off label for a postmenopausal woman or a man.

When a medication is prescribed off label it most likely will not be covered by your insurance and we cannot provide a prior authorization, but it is not illegal to prescribe off label. This is done at the discretion of the provider. Often medications are used off label because there is no FDA approved alternative treatment, or the side effects of the approved medication are not tolerated by the patient. If you have any questions with regard to your medication(s) being off label, please feel free to ask our providers.

I have been informed that the medication that I have been (or may be) prescribed is considered off label. I understand this medication was approved by the FDA for a different purpose and that this medication is not currently FDA approved for this specific use.

Nevertheless, I am willing to accept the potential risks that my physician discussed with me and acknowledge there may be other, unknown risks and that long-term effects and risks are unknown.

By signing below, I understand the risks and benefits related to this medication and consent to the prescription.
Signature *

Clear
Date *

Month Day Year
Date
PRESCRIPTION REFILLS AND PHARMACY POLICY

Please inform The SHOW Center which pharmacy you will be using and update the office as soon as a change occurs. It is your responsibility to notify the office in a timely manner when refills are necessary. Approval of your refill may take up to THREE (3) business days so please be courteous and do not wait to call. If you use a mail order pharmacy, please contact us within FOURTEEN (14) days before your medication is due to run out.

Medication refills will only be addressed during regular office hours. Please notify your provider on the next business day if you find yourself out of medication after hours. No prescriptions will be refilled on Saturdays, Sundays, or Holidays. Refills can only be authorized on medications prescribed by the providers from our office. We will not refill medications prescribed by other providers.

Some medications require prior authorization. Depending on your insurance, this process may involve several steps by the pharmacy, provider, and The SHOW Center staff. The providers and pharmacies are familiar with this process and will handle the prior authorization as quickly as possible. Only your pharmacy is notified of the approval status. Neither the pharmacy nor the provider can guarantee that your insurance company will approve the medication. Please check with your pharmacy or your insurance company for updates.

It is important to keep your scheduled appointment to ensure that you receive timely refills. Repeated no shows or cancellations will result in a denial of refills. All prescriptions require a follow up appointment every 3 to 6 months. If you have any questions regarding your medications, please discuss these during your appointment. If for any reason you feel your medication needs to be adjusted or changed, please contact us immediately. New symptoms or events require an office visit appointment. Your provider will not diagnose or treat over the phone.

Occasionally, short-term pain medication may be prescribed. It is not current practice that our providers will be prescribing long-term pain medication or narcotics. If we feel that your medical diagnosis requires narcotics, you may be required to obtain these medications through pain management or will need to sign a patient narcotic prescription policy agreement. This will be left up to the discretion of the provider.

Due to the nature of diagnoses made at The SHOW Center, many medications are not FDA formulated or are used off-label, and will need to be compounded. Compounded medications are not covered by insurance companies and will be an out-of-pocket cost to the patient. We try our best to work with you and several compounding pharmacies in the area to ensure the most cost- effective method.

By signing below, I hereby agree to and understand the prescription refills and pharmacy policy for The SHOW Center.
Signature *

Clear
Date *

Month Day Year
Date
CANCELLATION/NO-SHOW/RESCHEDULE POLICY

In order to provide the best care and service to our patients, we ask that you notify us 24 hours in advance to cancel and/or reschedule your office appointment.

Canceling an appointment last minute, or failing to show up for an appointment prevents someone else from being served who could have taken your place. There is also a lot of prep work involved for visit and we want to make sure you give us adequate time to reschedule you if it is needed.

If you forget or fail to show up for the appointment, there will be a $50.00 fee charged to your account. In addition, cancellation of a scheduled procedure requires 72 hour notice. Any cancellation not made 72 hours in advance will be subject to a $150.00 fee.

A reschedule fee of $75.00 will be charged each time a procedure appointment is rescheduled without proper cancellation.

By signing below, I hereby agree to and understand the cancellation/no-show/reschedule policy for The SHOW Center.
Signature *

Clear
Date *

Month Day Year
Date
OTHER CHARGES POLICY

Occasional, there will be services our office provides that cannot be billed to your insurance. We currently charge the following fees:

Disability/FMLA Forms: $25.00/form
Pre-Authorization Services: $25.00/encounter
Miscellaneous Letter Services: $25.00/letter
Phone Consultations: $25.00-$50.00/length
Copy of Medical Records: $0.25/page (medical release form must be signed prior to release of copies)
If you should have any questions regarding these fees, please reach out to our office.

By signing below, I hereby agree to and understand the other charges policy for The SHOW Center.
Signature *

Clear
Date *

Month Day Year
Date
Medical History/Gynecologic and Sexual Health Specific History
Sex Assigned at Birth *
Gender Identity
Reason For Visiting The SHOW Center *

Abnormal uterine bleeding (e.g.. irregular/heavy periods/unexplained bleeding) Postpartum Sexual Health Concerns Cancer and Sexual Health Concerns Painful Penetration Low Libido Perimenopause/Menopause Hormone Therapy Transgender Hormone Therapy Pelvic pain Vaginal or vulvar infection/irritation/dryness Orgasm Concerns Additional Sexual Health Concerns Genetic Testing Other
When did this concern start? *
Anything make it better? *
Worse? *
Does the concern interfere with normal routine or activities? Describe *
Can you relate this concern with any event or change in your life? (check all that apply

No relationship Pregnancy Childbirth Surgery Medication Menopause Accident/Injury Cancer Other
Have you been seen or managed for this condition in the past? *

Yes No
What medication are you currently on? *
Drug Allergies: *
Are you taking any supplements or medications?

No Yes
Food Allergies: *
Do you have a latex allergy? *

Yes No
Please list in greater detail your specific allergy and allergic reactions.
Age of first period? *
When was your last menstrual cycle? (date) *

Month Day Year
Date
If you are still menstruating, are your periods (check all that apply)

Regular Irregular Painful/bothersome Light to moderate Moderate to heavy Very heavy Not bothersome Other
Frequency of Menses/Period (cycle days) *
NA if not applicable
Length of Menses/Period (days bleeding) *
NA if not applicable
(date) *

Month Day Year
Date
What is your method of birth control? *
Have you ever had an abnormal PAP smear?

Yes No N/A
Abnormal vaginal discharge?

Yes No
When was your last mammogram? (date) *
NA if not applicable
Have you ever had an abnormal mammogram?

Yes No N/A
Do you perform self-breast exams?

Yes No
If yes how often?
Have you ever been pregnant? *

Yes, if yes check all that apply No Vaginal delivery Cesarean delivery Trauma during delivery Miscarriage Abortion
Number of Pregnancies
History of Infertility *

Yes No
Are you currently in a sexual relationship? *

Yes No have never been sexually active
Who are you sexually attracted to?

Men Women Both
Approximate number of lifetime sexual partners?
Sexual health concerns - check all that apply *

happy with sexual functioning pain with intercourse decreased sexual desire difficulty reaching orgasm vaginal dryness loss of feeling in genitals pain in genitals Other
Have you ever been diagnosed with a sexually transmitted infection? *

Yes No
History of physical, sexual, or emotional trauma/abuse?

Yes No
Do you feel safe in your relationship?

Yes No
If you said no to any of these questions, do you want to talk about it?

Yes No
Have you ever had any of the following vaccinations: Tdap (Tetanus), Gardasil (HPV) Series, and/or Flu Shot?

Yes No
History of female cancers?

Yes, if yes, check all the following: No
History of female cancers?

Vulvar Cervical Uterine Ovarian Breast Fallopian tube Vaginal
Medical History - check all that apply *

None Crohn's disease Migraine/Headache Allergies Depression Multiple Sclerosis Anemia Diabetes Myocardial infarction Gallbladder disease Osteoarthritis Angina Anxiety GERD (Reflux) Osteoporosis Autoimmune Glasses/Contacts Parkinson's disease Arthritis Hepatitis C Peptic Ulcer disease Asthma HIV/AIDS PTSD Atrial Fibrillation Seizure disorder Hyperlipidemia Blood clots Hypertension Spinal cord injury Cancer Irritable bowel disease Thyroid disease CVA/Stroke Kidney disease Urinary tract infections Liver disease Coronary Artery Disease COPD/Bronchitis Menopause Other
Any bone fractures?

Yes No
Other illnesses otherwise not listed. *
NA if not applicable
Have you had any surgeries in the past 5 years? *

Yes No
Previous Surgical History *

None Gastric bypass Bilateral tubal ligation Angioplasty Hernia repair Breast biopsy Cesarean section Hip replacement Angioplasty w/ stent D and C Knee replacement Appendectomy LASIK Surgeries/Procedures - check all that apply: Endometrial biopsy Back surgery Liver biopsy Hysterectomy Pacemaker CABG (heart bypass) Ovary removal Carpal tunnel release Plastic surgery Small bowel resection Mastectomy Cataract extraction Myomectomy Arthroscopy knee Breast reduction Thyroidectomy Cholecystectomy Other Tonsillectomy Colectomy Colostomy Breast augmentation Other
Family history - check all that apply *

None Mental illness Depression Tuberculosis Developmental delay Adopted Alcoholism Diabetes Obesity Eczema Osteoarthritis Allergies Asthma Hearing deficiency Osteoporosis Arthritis Heart attack PVD Blood disease Renal disease Hyperlipidemia Liver disease Hypertension Coronary artery disease Cancer Irritable bowel disease CVA/Stroke Learning disability Other
Physical History
Have you had issues with pelvic pain? *

Yes No
Do you have any pelvic pain/pressure/heaviness? *

Yes No
Do you lose urine when you:

I don't lose urine Cough/Sneeze/Laugh Lift/Dance/Exercise/Jump On the way to the bathroom When you have a strong urge to urinate Hear running water Directly after voiding Other
Quantity of leakage

None Drops Splashes More Other
Frequency of leakage

None Couple times a month Daily Weekly Other
Urinary History - check all that apply

I sometimes wet the bed I feel unable to empty my bladder completely I have burning/pain with urination I feel like my bladder is falling out of me It is sometimes difficult to start a stream of urine I have pain with a full bladder I strain/bear down to empty my bladder I have a very strong/immediate urge to urinate I urinate more that 7x a day None of the above Other
Bowel movement history - check all that apply

Regular bowel movements Rectal leakage Unable to control bowel movements Constipation Diarrhea Difficulty evacuating bowels Straining during bowel movement Pain with bowel movements None of the above Other
How many times per day or times per week do you move your bowels? *
Most common stool consistency?

Liquid Soft Firm Pellets/Hard Other
Lifestyle/Other
Exercise Activity

Light Moderate Vigorous Sedentary/None
Exercise days/week: *
Please list any hobbies/interests/recreational activities.
Hot flashes, sweating (episodes of sweating) *

None Mild Moderate Severe Extremely Severe
On average, how many hours of continuous sleep to you get a night? *
Do you have problems falling asleep? *

Yes No
Do you have problems staying asleep? *

Yes No
Depressive mood (feeling down, sad, on the verge of tears, lack of drive, mood swings) *

None Mild Moderate Severe Extremely Severe
Irritability (feeling nervous, inner tension, feeling aggressive) *

None Mild Moderate Severe Extremely Severe
Anxiety (inner restlessness, feeling panicky) *

None Mild Moderate Severe Extremely Severe
Physical and mental exhaustion (general decrease in performance, impaired memory, decrease in concentration, forgetfulness) *

None Mild Moderate Severe Extremely Severe
Weight gain/weight fluctuations *

Yes No
Hair changes, hair loss, change in hair texture *

Yes No
Alcohol Use

No Daily Weekly Less Former User
Tobacco Use

No Daily Weekly Less Former User
Caffeine Use

No Daily Weekly Less Former User
Are you interested in pelvic floor physical therapy?

Yes No
Are you interested in sex therapy/counseling?

Yes No
Any additional information you would like to provide regarding your visit?
Thank you for filling out our new patient paperwork today!
Should be Empty:

Welcome to The SHOW Center

Patient Information and Consents

Medical History/Gynecologic and Sexual Health Specific History

Physical History

Lifestyle/Other