Well Woman Exam Form

Due to privacy regulations, we can no longer ask you questions from the check-in window or out open in the lab. To expedite your visit, please complete the following:

1. Name:

DOB:

2. Address:

3. City:

State:

City:

4. Mobile Phone:

Home Phone:

5. Pharmacy Name:

Pharmacy number:

6. Email Address:

7. Reason for your visit:

8. Last menstrual cycle:

Drug allergies:

9. Medications:

10. Have you had any recent bloodwork in the past year?

Yes No

If yes, please specify with what doctor:

and when it was done:

11. Major illness and or surgery since your last visit:

Yes No

If yes, please specify:

Please provide a current insurance card and driver’s license:

Add file

Please upload a file

Dear Patient:

Your physician may order labwork as part of your routine exam. Your insurance may or may not cover” the labs under a routine diagnosis. You have the option to contact your insurance company prior to having labs run. If you prefer to have your labs drawn today, please understand you may receive a bill from Labcorp or Quest and you will be responsible for payment.

By signing below, you are authorizing the ordered fees 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.

Patient Signature:

Date:

Bay Area Obstetrics and Gynecology

Date:

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

The undersigned understands that Bay Area Obstetrics and Gynecology, PA, Inc. is required by law to maintain privacy of protected health information and has provided the patient/patient’s representative with a notice of its. privacy practices regarding health information.

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.

Patient's Name:

Date of Birth:

Patient Signature:

Patient's representative (If applicable):

Relationship to patient:

Please list below the person(s) we can release your health information to. (Please note: In an emergency or other situation outlined in our Notice of Privacy Practices, we may share information with others who are not specifically listed on this form.)

Add name

What Is the best phone number for us to contact you?

From time to time, we will leave a message for you (as stated in our Notice of Privacy practices) on an answering machine, voice mail, or with another individual in your absence. (Such as diagnosis and medication).

Is it ok to leave a detailed message on the above phone number?

Yes No

For Bay Area Ob-Gyn office use only:

An attempt was made to obtain a written acknowledgement of receipt of our Notice of Privacy Practices, but the acknowledgement could not be obtained due to:

The individual refused to sign Communication barriers prevented us from obtaining the acknowledgement An emergency situation prevented us from receiving the acknowledgment Other

If Other, please specify:

Your information will be encrypted.

Well Woman Exam Form

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

For Bay Area Ob-Gyn office use only:

BAY AREA OBSTETRICS & GYNECOLOGY, P.A.