ESTABLISHED PATIENT REGISTRATION

As an established patient we must update your records annually. Please complete all four forms below for our records to maintain an up to date chart. If you have any questions, please contact us. Thank You.

1. Established Patient Registration | 2. Privacy Agreement Form | 3. Credit Policy Form | 4. OB/GYN History Form

Please take the time to complete our obstetrical / gynecological new patient registration. This information will be made part of your permanent chart and will not be released to any other entity unless expressly requested by you.This form is secure and all information is encrypted to protect your personal information.

PERSONAL INFORMATION
Today's Date :
First Name:
Last Name:
Birth Date :
Social Security # :
Address:
City:
State:
Zip:
Cell Phone:
Home Phone:
Work Phone:

Email Address:
If you entered your email address, may we advise you via email of your normal lab results? Yes No (Please note that no medical information will be emailed. All abnormal results require follow-up via a telephone call.)
May we send an electronic reminder when your pap smear is due? Yes No

Patient School / Employer::
Emergency Contact:
Emergency Phone:
Preferred Pharmacy:
Pharmacy Telephone:
If insured is not the employee:
Insured Member:
Insured Date of Birth:
Insured Employer:
Insurance Company:
If the insured does not live in your household please complete the following:
Address::
City:
State:
Zip:
Insured Phone:
Employer:
How did you hear about our ofice?
I hereby assign provider at Arboretum Obstetrics & Gynecology all payments for health care services rendered to me. I understand that I am personally responsible for any financial amounts not covered by my insurance plan. Arboretum Obstetrics & Gynecology will make reasonable efforts to notify me in advance about services that may not be covered by my insurance.
Patient:
Date: