New Patient Form English

Name

First NameMiddle NameLast Name

Address

Street Address

Apt

CityState / Province

Postal / Zip Code

Cell phone

xxx-xxx-xxxx

Home phone

xxx-xxx-xxxx

Work phone

xxx-xxx-xxxx

Email Address

example@example.com

Date of birth

Date

Age

SSN

Last menstrual period: last menstrual period Certain (yes/no): yes/no

Marital status: (please select appropriate box)

Referring Provider Name

Do we have your permission to: Leave a message on your answering machine at home?

yesno

Do we have your permission to: Leave a message on your cell/home phone?

yesno

Do we have your permission to: Leave a message on your answering machine at work?

yesno

Do we have your permission to: Discuss your medical condition with any member of your household?

yesno

If yes, with whom? blanks field. Relationship blank .

Your Occupation

Your Employer

Employer's Address

Employer's Street Address

Employer's Street Address Line 2

CityState / Province

Postal / Zip Code

Spouse or Partner's Name

Spouse or Partner's Cell Phone Number

Spouse or Partner's Work Phone Number

Spouse or Partner's Other Phone Number

Emergency Contact (if other than partner or spouse): Name: blanks Phone:Type a label Relationship: blank

Primary Insurance Information (Please complete if you are NOT the primary insured) Primary Insurance Company Primary Insurance Company Policy ID# Type a label Group # blank Claims Mailing Address Street Address City City State State Zip Zip

Policy Holder's Name policy holder's name Policy Holder's DOB policy holder's DOB Policy Holder's SSN policy holder's SSN Relationship to patient relationship to patient

Secondary Insurance Information (Please complete if you are NOT the primary insured) Secondary Insurance Company Primary Insurance Company Policy ID# policy ID # Group # blank Claims Mailing Address Street Address City City State State Zip Zip

Policy Holder's Name policy holder's name Policy Holder's DOB Type a label Policy Holder's SSN Type a label Relationship to patient Type a label

Please Note: If your insurance company requires that you bring a referral, you as the patient are responsible for contacting your primary care physician (which may different from your Ob/Gyn) prior to your visit to obtain a referral. If you do not obtain your referral prior to your appointment, we may need to reschedule your appointment. It is the patient's responsibility, solely, to understand their individual benefits.

Signature*

Date

RELEASE AND ASSIGNMENT

I hereby authorize the Pregnancy Specialty Center of Texas to release my insurance carrier all information concerning my illness and treatment and hereby assign the Pregnancy Specialty Center of Texas all payments for medical services rendered to myself and/or my dependents. I understand that I am fully responsible for any amount NOT covered by my insurance carrier.

Signature*

Date

RECEIPT OF NOTICE OF PRIVACY PRACTICE WRITTEN ACKNOWLEDGEMENT FORM

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that information can and will be used to:

- Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.

- Obtain payment from third-party payers for my health care services

I have been informed of my provider’s Notice of Privacy Practices containing a more complete description of the uses of disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my provider has the right to change the Notice of Privacy Practices and that I may contact the office to obtain the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment of healthcare operations, and I understand that you are not required to agree to my requested restriction, but if you do agree then you are bound to abide by such restrictions.

Signature*

Date

AUTHORIZATION TO RELEASE MEDICAL RECORDS

I hereby authorize the Pregnancy Specialty Center of Texas to release any and all information related to my past and present medical history, diagnoses, and treatments to my referring provider and other PCP, or specialist that will be treating me during my illness and treatment. I understand that any records not related to my illness and treatment will not be released.

Signature*

Date

FINANCIAL RESPONSIBILITY

I understand that I am personally responsible for any medical fees I will incur at the Pregnancy Specialty Center of Texas. I also understand that I will be responsible for any charges incurred by not providing the most current, correct insurance information to the Pregnancy Specialty Center of Texas. I understand that my insurance benefits may have an “allowable amount” for each procedure that is determined by the benefit contract I have with the insurance company and does not always equal the doctor’s fee. We are contracted with most insurance companies and would make the necessary allowable adjustments accordingly. My insurance may pay a percentage of the “allowable,” and I understand that I am responsible for payment of the remaining allowable balance. This payment may include my deductible (if not already satisfied), any co-payments, and any remaining portion of the doctor’s bill that is not covered. The portion estimated to be my responsibility will be due at the time of service. I understand that medical benefit policies may not pay for their entire treatment.

I understand I am financially responsible for services received from the Pregnancy Specialty Center of Texas.

Signature*

Date

Have you ever had:*

	Yes	No	Comments
Anemia
Arthritis
Asthma
Back problems
Blood clotting disorder
Blood transfusion
Cancer
Cervical Surgery (i.e. LEEP/CONE)
Depression
Diabletes
Heart problem/murmurs
Chronic hypertension
Lupus/autoimmune disorder
Seizures
Migraines
Sexually transmitted disease
Surgery
Thyroid disease
Hepatitis
Other

Cigarettes

	Yes	No	If yes how many a day
Do you smoke cigarettes?

Alcohol

	Yes	No	If yes how many drinks a day
Do you drink alcohol?

Drugs

	Yes	No	If yes which kind and how often do you use them
Do you use any drugs?

Are you taking prenatal vitamins?

yesno

Other medications

	Yes	No	If Yes please note type and dosage
Any other medications (prescription or over the counter)?

Other medications

	Yes	No	If Yes please note type and dosage
Did you take any other medication(s) earlier during this pregnancy?

Allergies

	Yes	No	If Yes please let us know which medications and what reactions you develop
Are you allergic to any medications?

Estimated due date given to you by your primary provider

Do you have any complaints presently?

yesno

If you currently have any complaints, please describe

Total number of pregnancies including this one

Please list live births below

	Date	Weight	Full Term?	Boy/GIrl	Vaginal/CS	Complications
1
2
3
4
5
6
7

Please list miscarriage(s) below

	Date	Gestational age	Reason if known
1
2
3
4

Please list terminations below

	Date	Gestational Age	Medical or Surgical
1
2
3
4

Blood type (if known):

ABABO

Rh if known:

positivenegative

Partner's DOB: blanks Age: blank Your Race: Type a labelPartner's Race partner's race Ethnic Background (Italian, Irish, Asian, German, Polynesian, African, etc): Yours: your ethnic background Partner's partner's ethnic background Have you or your partner had genetic screening / testing? Type a label

Family history: Have you, your partner, your children or any other members of your family had any of the following conditions?

	Yes	No	Who	Explain
Blindness
Blood Clotting Disorders (i.e., Pulmonary Embolism/DVT/MTHFR/Protein C or S Deficiency
Bone disorders or short stature
Cancer of early onset (under 45 years of age)
Chromosome abnormality
Cleft lip and/or palate
Cystic fibrosis
Deafness
Down syndrome
Epilepsy/seizure disorder
Genital abnormality
Heart defect (as child)
Hemophilia / bleeding disorder
Huntington's disease
Hydrocephaly (fluid or water on the brain)
Infertility/Multiple miscarriages (more than 2)
Kidney Defects
Limb Defects
Mental Illness
Intellectual disability / significant learning disability
Muscular Dystrophy
Neurofibromatosis
Sickle Cell Disease / Thalassemia
Spina Bifida / Anencephaly
Tay Sachs Disease
Multiple family members with the same trait

PRUDENT USE AND CLINICAL SAFETY OF DIAGNOSTIC ULTRASOUND

Approved March 19, 2007

Diagnostic ultrasound has been in use since the late 1950’s .Given its known benefits and recognized efficacy for medical diagnosis, including human pregnancy, The American Institute of Ultrasound in Medicine herein addresses the clinical safety of such use:

No independently confirmed adverse effects caused by exposure from present diagnostic ultrasound instruments have been reported in human patients in the absence of contrast agents. Biological effects have been reported in mammalian systems at diagnostically relevant exposures, but the clinical significance of such effects is not yet known. Ultrasound should be used by qualified health professionals to provide medical benefit to the patient.

PRUDENT USE IN OBSTETRICS

Approved March 19, 2007

The American Institute of Ultrasound in Medicine advocates the responsible use of diagnostic ultrasound and strongly discourages the non-medical use of ultrasound for entertainment purposes. The use of ultrasound without a medical indication to view the fetus, obtain a picture of the fetus or determine the fetal gender is inappropriate and contrary to responsible medical practice. Ultrasound should be used by qualified health care professionals to provide medical benefit to the patient.

INFORMED CONSENT FOR ULTRASOUND

Your physician has requested that you undergo a diagnostic procedure known as an ultrasound. Simply stated, this procedure involves the transmission of sound waves reflected off your womb and your fetus, which will be monitored and recorded to obtain information concerning your pregnancy. This test is believed to carry with it very little risk to you or your fetus.

The standard ultrasound takes approximately 10-30 minutes to perform and may provide information concerning placenta location, fetal position, multiple gestation, approximate gestational age, and the possible presence of gross fetal malformations. This test, however is not definitive for the absence of fetal malformations, and despite normal interpretation of the test, some babies are born with anomalies not identified by the examiner during the ultrasound study. Thus, although ultrasonography is a helpful diagnostic tool, it does not absolutely determine the absence of fetal defects. This type of exam is also done prior to performing genetic amniocentesis.

Should you have any questions concerning ultrasonography, discuss them with your referring physician before undergoing the procedure. You are requested to sign this document prior to the performance of this exam, thereby acknowledgement that you have read and have understood the information contained herein, and have given an informed consent to this procedure, and are aware of the risks involved.

Signature*

Date

NEW PATIENT INFORMATION

Phone Numbers

MEDICAL HISTORY

Medications

PREGNANCY HISTORY

FAMILY HISTORY