New Patient Packet

Please correct the errors described below.

Patient Registration Form

Patient Information

(as it appears on Insurance card or ID)

Patient Employer/School Information

Emergency Contact Information

Billing and Insurance

Primary Health Insurance

(as it appears on Insurance card or ID)

Secondary Health Insurance

{as It appears on Insurance card or ID)

Responsible Party

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Reason for Visit

Current Medications

What medication are you currently taking?

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Allergies

Do you have any other allergies?

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Past Medical History

Post Surgical History

Family History

Has anyone in your family ever had any of the following conditions?

Lifestyle Factors

OBGYN History

Pregnancy History

Please describe any pregnancies you have had.

Past Pregnancies

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Menstrual History

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Health Exams

Please check and date all immunizations you have had.

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Please check and date tests you have had.

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Cancer Family History Questionnaire

PERSONAL INFORMATION

Instructions: This is a screening tool for cancers that run in families. Please mark CV) for those that apply to YOU and/or YOUR FAMILY. Next to each statement, please list the relationship(s) to you and age of diagnosis for each cancer in your family. You and the following close blood relatives should be considered: You, Parents, Brothers, Sisters, Sons, Daughters, Grandparents,Grandchildren, Aunts, Uncles, Nephews, Nieces, Half-Siblings, First-Cousins, Great-Grandparents and Great-Grandchildren

YOU and YOUR FAMILY's Cancer History

(Please be as thorough and accurate as possible.)

Breast Cancer

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Add new row for another relative on your mother's side

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Ovarian cancer (Peritoneal/ Fallopian tube)

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Endometrial (Uterine) cancer

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Colon/rectal cancer

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Add new row for another relative on your mother's side

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10 or more Lifetime Colon/ Rectal Polyps

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Add new row

Add new row

Pancreatic cancer

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Add new row for another relative on your mother's side

Add new row for another relative on your father's side

Prostate cancer

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Add new row for another relative on your mother's side

Add new row for another relative on your father's side

Other Cancer(s)

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Add new row for another parent/ sibling/ child

Add new row for another relative on your mother's side

Add new row for another relative on your father's side

BREAST CANCER RISK MODEL INFORMATION

If yes, are you a:

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CANCER RISK ASSESSMENT REVIEW

(To be completed after discussion with your healthcare provider)

Office Use Only

Authorization of Ordered Tests

Dear Patient, Your physician may order lab work as part of your routine exam. Your insurance company mayor may not cover the labs under your Well Woman exam diagnosis. You have the option to contact your insurance company prior to your exam to verify which tests are covered on your Well Woman exam. If you prefer to have your labs drawn at your visit without verifying coverage first please understand you may receive a bill from the lab. By signing below, you are authorizing the ordered tests and understand you may receive a bill.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Thank you, Bay Area Ob-Gyn

Medical Treatment Consent Form

This will verify that I hereby authorize any and all physicians at Bay Area Ob-Gyn or those designated by them including ancillary personnel to evaluate, diagnose, treat and otherwise care for including all necessary tests or procedures, whether in our office or elsewhere. This permission is valid until revoked by written notice to Bay Area Ob-Gyn.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

STATEMENT OF FINANCIAL RESPONSIBILITY

I understand that I am personally obligated to pay all physician bills from Bay Area Ob-Gyn for services rendered to me. I understand that the physician bills are separate from and do not include charges made by the hospital, outside laboratories and other physicians. The fact that I may be covered by insurance does not relieve my personal obligation to pay all my physician bills; including bills for non-covered services and any amounts applied to co-pays, deductibles and co-insurance. I authorize the release of any medical or other information necessary to process my insurance claims. I also request payment of government benefits either to myself or to the party who accepts assignment below. I authorize payment of medical benefits to the provider of any services for Bay Area Ob-Gyn. I agree to pay at Webster, Harris County, Texas the charges of Bay Area Ob-Gyn.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your message will be encrypted and can only be read by BAY AREA OBSTETRICS & GYNECOLOGY, P.A..