New Pt

Women's Wellness Center

645 Sierra Rose Drive # 204 Reno, NV 89511 Phone (775)-352-9355 Fax (775)-352-3575
Patient Demographic Form
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Social Security #
Marital Status
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Number *

Area Code Phone Number
Secondary Number

Area Code Phone Number
Email
example@example.com
Employer
Employer
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Responsible Party Name (if patient is a minor)
Do you have active insurance? *

Yes No, I will be cash pay
If you have insurance, please fill out below fields and bring your insurance card to your visit. There are some insurance plans we do not accept, please confirm your plan with our office, before your appointment.
Primary Insurance Company
Policy Holder
Insurance ID #
Secondary Insurance Company
Policy Holder
Insurance ID#
Primary Care Physician
Referring Physician

Financial Contract/Agreement
1. I understand that if I do not pay my account with Women's Wellness Center in full, my account may be assigned to a collection agency for collection.

2. I understand that if my account is assigned to a collection agency, the collection agency will charge a commission or fee that may be as much as 50% of the amount I owe to Women's Wellness Center. I agree that if my account is assigned to a collection agency, Women's Wellness Center may add the amount of the collection agency's comission or fee to the amount I owe to Women's Wellness Center and I agree to pay the additional amount.

3. I understand and agree that in the event, legal action is commenced to enforce my obligations, I will pay court costs and attorney's fees.
Date *

Month Day Year
Date
*Please note that hiring a collection agency, should your account be delinquent, is the last alternative made by the billing department. The billing department is very attentive in giving ample notice before an account is sent to collections. Furthermore, options for payment plans are available when approriate. Should this payment plan be neglected, a warning notice will be sent prior to involving a collection agency. Refusing to sign this agreement will not prevent delinquent accounts from being sent to collections.
HIPPA
I, First Name Last Name have reviewed or have access to, the Notice of Privacy Practices for Women's Wellness Center. (located on Web Site)
Signature *

Clear
Date *

Month Day Year
Date

Laboratory, Radiology, & Pharmacy
Pap smears will be sent to Aurora Laboratory, unless insurance is through Anthem - Aurora accepts all other insurance plans.
Preferred Lab for blood work *
For radiology services, such as ultrasounds and mammograms, I prefer to use *
Other preferred radiology facility (if not listed)
I am aware that I am responsible for knowing my preferred lab. I will be responsible for any charges incurred that my insurance may not cover.
Pharmacy *
Location
Street
Do you have an Advance Directive (Living Will)? *
Please be advised, if you are over 40, a Fecal Occult Blood (FOB) test will be performed during your annual exam in order to test for blood in your stool. This test may or may not be covered by insurance and the total cost is $28.00.

Release of Protected Health Information
If you want your medical information shared with another person (spouse, parent/guardian, or relative) they must be listed on this form in order for us to share any information. This applies to minors as well. We will not share any health information without consent.
I, First Name Last Name give Women's Wellness Center permission to share my protected health information with First Name Last Name- relationship to patient .

If you do not wish to have any of your health information shared with anyone, please type declined here: This applies to minors as well.
Do you give Women's Wellness Center permission to share your protected health information with your Primary Care Physician? *
Name of Primary Care Physician First Name Last Name
This authorization is in effect for one year from date signed.

	NONE	CURRENTLY	PAST
Muscle weakness

Medication Sheet
Please list all MEDICATIONS AND VITAMINS

	NONE	CURRENTLY	PAST
Weight loss
Weight gain
Fever
Fatigue

	NONE	CURRENTLY	PAST
Ear Aches
Ringing in ears
Sinus problems
Sore Throat
Mouth sores
Dental problems

	NONE	CURRENTLY	PAST
Painful breathing
Chest Pain
Difficult breathing on exertion
Swelling of legs
Heart palpitations

	NONE	CURRENTLY	PAST
Wheezing
Spitting up blood
Shortness of breath
Cough, chronic

	NONE	CURRENTLY	PAST
Diarrhea, frequent
Bloody stool
Nausea/vomiting
Constipation

Women's Wellness Center

Patient Demographic Form

Financial Contract/Agreement

HIPPA

Laboratory, Radiology, & Pharmacy

Release of Protected Health Information

Intake History

Medication Sheet

Personal past history of major illness:

Gynecologic Intake History

OB History

Operations/Hospitalizations

Family History

Social History

Personal Profile

	NONE	CURRENTLY	PAST
Blood in urine
Pain with urination
Urgency
Frequency of urination
Incomplete emptying
Leaking of urine
Abnormal periods
Painful intercourse

	NONE	CURRENTLY	PAST
Bruises, frequent
Cuts do not stop bleeding
Enlarged lymph nodes

	NONE	CURRENTLY	PAST
Double vision
Spots before eyes
Vision changes

	NONE	CURRENTLY	PAST
Pain in breast
Discharge
Masses
Rash
Ulcers

	NONE	CURRENTLY	PAST
Migraine headaches
Dizziness
Seizures
Numbness
Trouble walking

	NONE	CURRENTLY	PAST
Dry skin
Abnormal thirst
Hot flashes