• NEW PATIENT REGISTRATION

    Please note that it is important to fill in all the fields before submitting. Thank you.

  • General Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Check One:
  • Marital Status:

  • Patient Information -

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year

  • Spouse/Parent (If minor) Information -

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Emergency Contact Details -

  • Format: (000) 000-0000.

  • Relative or Friend not living at same address: -

  • Format: (000) 000-0000.

  • Primary Insurance -

  • Secondary Insurance -

  • Patient History

  • Select All that Apply -

  • List all surgeries -

  • Approximate Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approximate Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approximate Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approximate Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approximate Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Approximate Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Number of:

  • Please list ALL previous pregnancies in chronological order:

  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Sex
  • Will you permit a blood transfusion for medical reasons?
  • Are your periods regular?
  • Date of last menstrual period:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Any problems with periods?
  • Do you want to change birth control?
  • With respect to your female organs, have you ever had: Select all that apply -
  • Have you ever had an abnormal Pap Smear?
  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have you completed the HPV vaccine series (Gardasil)?

  • List all currently used medications -

  • Genetic: If you or your husband are in the following categories, please respond -

  • If of African American or Indian descent, have you or your husband had Sickle Cell carrier testing?
  • If of Italian or Greek descent, have you or your husband had Thalassemia carrier testing?
  • If of Jewish descent, have you or your husband had Tay-Sachs carrier testing?

  • Social History -

  • Do you drink alcohol?
  • Do you smoke?
  • Are you using any other drugs?
  • Are you sexually active?

  • Family History: Is there a member of your family with a history of -


  • Date of last Pap Smear:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last Mammogram:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of last Bone Density:
     - -
    2 digit month, 2 digit day, 4 digit year
  •  -
  •  -
  • Date :
     - -
    2 digit month, 2 digit day, 4 digit year

  • Notice Regarding Your Well Woman Exam

  • T. L. Jenkins M.D., P.A. complies with insurance coding guidelines from the American Medical Association (AMA). At your visit today your physician will provide a medical service and will submit codes to your insurance company according to the guidelines mandated by the AMA. We wish to share with you the difference between an “Annual Exam” and “Problem Visit”.

    Please understand that our goal to give you the best medical care as well as making you aware of insurance guidelines with which we are also responsible.

     

    Annual Exam (Well Woman Exam):

    • An annual exam is preventive annual care without any medical problems
    • Some insurance companies DO NOT require co-pay for an annual.
    • In general, if you are in need of prescription or test for a medical problem or issue, this is considered by your insurance company and the AMA to be a “problem visit” and will be billed accordingly.
    • If a problem such as a breast lump is found at your “annual exam”, the exam is no longer considered by the AMA guidelines as an annual exam. Both of these examples are problem visits and will be coded accordingly.

     

    Problem Visit (I.e.: irregular or heavy cycles, painful intercourse, urinary problems, etc.):

    • If you are having any problems that you need to address with your doctor during this visit feel free to do so. However, your visit must be coded as a “problem visit”, and will be billed in addition to your well woman exam. All codes and diagnosis are generated by your physician at the time of service in accordance with national standards set by the AMA. Most insurance companies DO require a payment for this visit.
    • If you are in need of a prescription or test for a medical problem or issue, this is considered by your insurance company to be a “problem visit” and will be charged separately.

     

    If you have any questions or concerns regarding this notification, please discuss it with our front desk prior to being brought back to an exam room.

  • Date :
     - -
    2 digit month, 2 digit day, 4 digit year

  • Attention patients who currently have or are considering enrollment in a Medicaid plan:

  • Please be advised that certain providers in this office accept Texas Medicaid plans as secondary insurance only. These plans are Traditional Medicaid, QMB, Amerigroup (non-pregnant patients only), and Community Health Choice. We are not contracted with any other Medicaid plans, including CHIP. If you receive care from any providers employed by Jenkins Ob/Gyn and have any plan besides those which we are contracted with, you are considered out of network, and subsequently you will be financially responsible for your care. If you have any commercial insurance (i.e. BCBS, Aetna, United Healthcare, etc.) at the time of your appointment, regardless of having an active or pending Medicaid plan, you must notify our staff and provide us with the policy information prior to being seen. As required by State law, we will file your claim with your private insurance first and Medicaid as a supplementary payer. It is necessary to provide this information to prevent inaccurate billing and to avoid your personal, financial liability after care as been established.

  • Please check the box that applies to you:*

  • It is important that you provide us with all insurance information at each visit in order for us to accurately bill. The omission of any additional insurance other than your Medicaid plan makes accurate billing difficult. Please understand that this is also considered fraudulent. Jenkins Ob/Gyn does not support any such activity. Any deliberate, fraudulent actions will be grounds for discharge from our practice and you will be financially responsible.

  • Date :
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: