• PATIENT REGISTRATION

  • New patients MUST arrive 15 minutes prior to your scheduled appointment time, or you will be asked to reschedule. If you cancel your first appointment in advance, we are happy to reschedule; however, if you miss the following appointment, you will not be allowed to reschedule with our office. If you no show your first appointment your account will be marked inactive, and you will not be allowed to reschedule. Our office is NOT responsible for checking your benefits prior to scheduling; please confirm your benefit coverage with your insurance plan prior to making an appointment.

  • Primary#:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth:*
     - -
  • Relationship Status:*
  • Gender:*
  • Preferred Pronoun:*
  • Sexual Orientation:
  • Race:*
  • Ethnicity:*
  • Preferred Language:*
  • Interpreter Services Requested:*
  • Preferred Provider:
  • Were you referred by a doctor?

  • PRIMARY Insurance Information:

  • Policy Holder Date of Birth: *
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • SECONDARY Insurance Information

  • Policy Holder Date of Birth:
     - -
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • PARENT / SPOUSE INFORMATION:

  • Format: (000) 000-0000.

  • EMERGENCY CONTACT INFORMATION:

  • RESPONSIBLE PARTY:

    (If other than yourself)
  • Format: (000) 000-0000.

  • PLEASE READ AND INITIAL EACH SECTION:

    INSURANCE AUTHORIZATION AND FINANCIAL AGREEMENT:
    I understand that payment for all services is due at the time of visit, including copays. I understand it is my responsibility to know and understand my insurance benefits. If any visit requires an additional procedure, I understand that my insurance may require I pay an additional fee. If I am unable to present a current insurance card, I will be classified as “selfpay.” Payment for said visit will be due at the time of service. I give Lakeshore Women's Specialists permission to apply for benefits on my behalf, and authorize my insurance benefits to be paid directly to Lakeshore Women's Specialists. I authorize the release of pertinent medical information necessary to process my claims. I certify that the information provided by me in regard to my insurance coverage is correct. I will be prepared to present my correct insurance card at every visit. Lakeshore Women's Specialists charges $15.00 for your medical records.   *   

    CONSENT FOR HEALTHCARE AND RELEASE OF MEDICAL INFORMATION:
    I voluntarily consent to healthcare treatment from the providers and staff at Lakeshore Women's Specialists. I am aware that the practice of medicine is not an exact science. No guarantees have been made to me regarding the result of my treatment or examinations. I consent to the use and disclosure of protected health information about me for treatment, payment and healthcare operations. I have read this form. I have had the opportunity to ask questions and my questions/concerns have been answered.   *   

    ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES:
    Notice of Privacy Practices is available on our website under patient resources or you may receive a copy in office. The Notice describes how Lakeshore Women's Specialists may use and disclose of my healthcare information, and rights I may have regarding my protected health information. I am aware the Notice may be changed at any time. I may obtain a revised or additional copy at any time.   *   

    PATIENT RECORD SHARING:
    Record sharing allows my clinical chart of Lakeshore Women's Specialists to be available to other authorized providers for continuum of care. This allows care settings to connect my records so information can be accessed between treating providers. I consent to sharing my clinical documents and I am aware I have the right to opt-out at any time.   *   

  • HEALTH HISTORY

  • GYN History:

  • Abnormal PAP?*
  • STD:
  • Please choose current activity:

  • Menses:

  • First Day of Last Period:*
     - -
  • Regular Cycles?*
  • Current Contraception:*
  • LATEX?

  • Tobacco Usage:

  • Have you ever?
  • Currently?
  • Alcohol Usage:
  • Other Drug Usage:
  • Will you accept a blood transfusion in the event of a life-threatening emergency?

  • MEDICAL HISTORY:

  • Rows

  • Family History:

  • Rows

  • PRIVACY RELEASE OF INFORMATION

  • In order to serve you better, please complete this form allowing us to communicate with a list of people with which we may discuss your health information. Those noted on your list must provide your date of birth in order to receive any information.

  • Date of Birth
     - -
  • APPOINTMENT REMINDERS:
  • RESULTS:
  • Format: (000) 000-0000.
  • EMAIL COMMUNICATION:
  • Format: (000) 000-0000.

  • Anyone calling the office, including yourself, on your behalf MUST provide your password before any information can be discussed. Thank you.

     

    Patient Information

    I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or receive a copy of the protected health information disclosed, as described in this document. I understand that a revocation is not effective in cases where the information was already disclosed, but will be effective going forward. I understand the information used or disclosed as a result of this authorization may be subject to disclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient.

  • Date
     - -

  • REQUEST OF MEDICAL RECORDS

  • PATIENT INFORMATION:

  • Date of Birth:
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • To Release:
    (Note: We are not a PCP provider, please do not request your complete chart to be sent to our office, only necessary records. i.e. labs, pathology, mammogram, last 3 years of office notes)

  • Purpose of Disclosure:

  • I do hereby authorize disclosure of the health information for the above named patient. The authorization is valid for 12 months from the date of signature. I understand that I may cancel this request with a written notification, but it will not affect any information released prior to cancellation. I understand that the information used or disclosed may be subject to re-disclosure by the person or facility receiving it and would then no longer be protected by this release. I understand the medical provider to whom this authorization is furnished may not condition its treatment on me on whether or not I sign the authorization.

  • Date
     - -
  • Should be Empty: