Basic Information Form

Welcome to Applegate Health Care, office of Tabitha Barron, WHNP

Client Information

First name

Last name

Phone Number

Email address

Date of Birth

Mailing Address

Please include city and zip

Do you currently have insurance?

Yes No

If yes, please list:

i.e Blue Cross, Regence, Pacific Source, Medicare

Medical History

Do you have a Primary Care Provider (PCP)? Please note we are only accepting new patients for GYN concerns at this time.

Yes No

If yes, name of PCP:

Current Medications:

Is there a chance that you are pregnant?

Yes No

What type of appointment would you like to schedule for?

ie: hormone eval, PMS, birth control, pap smear, etc

Checkbox

By checking this box I acknowledge that Applegate Health Care requires 24 hour notice to reschedule. I understand if I no-show my first appointment I will not be rescheduled.

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