First Coast Obstetrics & Gynecology Paperwork

WELCOME TO OUR PRACTICE

Name

Date of Birth

Date

Address

City

State

Zip

SS#

Phone

Secondary Phone

Email Address

Consent to Text

No Yes

Problem Visit

If yes, what?

List Current Medications

Who is your primary care provider?

What is your primary Pharmacy?

In which language do you communicate?

In case of Emergency, whom may we contact

Phone

Relation

We are required by law to ask which RACE and what ETHNICITY best describes you (you may decline to answer)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White

Hispanic or Latina

Not Hispanic or Latina

Other

Decline to report

If Other, please specify

Please complete Insurance Information

Insurance Co.

Policy Number

Name of Insured

Date of Birth

Relationship

Assignment of Insurance Benefits

(FINANCIAL STATEMENT POSTED IN LOBBY)

I hereby authorize direct payment of surgical or medical benefits to First Obstetrics & Gynecology, PA for services rendered. I understand that I am financially responsible for any balance not covered by my insurance.

I hereby authorize First Coast Obstetrics & Gynecology, PA to release any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I understand I may revoke this consent at any time by notifying First Coast Obstetrics & Gynecology, PA in writing. First Coast Obstetrics and Gynecology, PA has the right to refuse treatment should I revoke or refuse this consent.

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.

Signature

Date

Consent for Medical Information Release

There are times we are asked to give family members or other information on test results, especially if you will not be available to receive them. If you would like for us to give out information regarding your treatment and/or test results to your family or friends, please fill in their name and their relationship to you. Make your own notes if necessary for clarification.

Add Additional Name

Please check here if No information is to be released

I give my consent to the individual (listed above) permission to receive my Medical Information, such as, lab results, imaging results, appointments, and financial information from First Coast Obstetrics and Gynecology

Signature

Date

Gynecologic History

Date of last menstrual period

Date of last Mammogram

Date of last Colonoscopy

Date of last Bone Density

Date of last Pap Smear

If yes, when?

If yes, When?

Treatment

If yes, When?

Treatment

If yes, Type of birth control:

If IUD, What type?

Age of onset of period?

If menopausal, age of time of last period

How many days of cycle?

Any GYN history we should know about?

Obstetrics History

How many pregnancies have you had total (including miscarriages)?

How many deliveries?

If yes, When?

If Yes, What/When?

Delivery History

Add Additional History

Office Policies

(Please see our full detailed Office Policy, located in lobby)

Your copay is due at the time of service. You are responsible for any deductible insurance amounts.
If your insurance requires a referral or authorization, it is your responsibility to get it.
Your insurance company has contracted with a lab for any blood work, Pap smear, or biopsies; you should know which lab to visit for blood work. We will make every attempt to send any specimens to the correct lab.
Please give a 24-hour notice for cancellations.
You may be charged for a $25 NO SHOW FEE. Please call our office to cancel or reschedule prior to your scheduled appointment time to avoid any charges. After 3 no show appointments, no more appointments will be made. You may come in and sit in our lobby and wait to be seen. Please note, all scheduled appointments will be seen first.
There is a $25.00 charge for FMLA paperwork, and may take up to 3 days to complete. There is a $30.00 charge to fax FMLA paperwork.
You must contact our office if you will be more than 15 minutes late for your appointment. Note, you may be rescheduled, if you are more than 15 minutes late of your scheduled appointment time.
You are required to contact First Coast Obstetrics and Gynecology, PA if your insurance or contact information changes at any time.
In addition to our regular office hours, our practice has coverage 24hrs a day/7 days a week. If you are in labor after hours or have a question that can’t wait, please call our office and speak to our call service to have them direct you to our provider on call. For immediate care, please call 911 or go to the nearest hospital. You can also direct non-emergency questions through the patient portal. They will be answered the next busy day.

I have read and understood the Office Policy of First Coast Obstetrics & Gynecology

Signature

Date

Notice of Privacy Practices

I have read and understood the “Notice of Privacy Practices”. A printed copy is located at the front desk. Upon request, you may take one.

Signature

Date

Social History

Cig/day

Years of use

Type

amount/day:

List All Surgeries:

Add Additional Surgery

Additional Notes:

Medical History

Other:

Family History

Please list IF your parents, siblings, maternal or paternal grandparents have medical conditions

Add Additional Family Member

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