NEW PATIENT INFORMATION FORM

Are you insured with MEDICARE? *
Name *
Name
When was your last pap smear? *
When was your last pap smear?
When was your last mammogram? *
When was your last mammogram?
Are you taking any medications? *
Are you currently using anything for birth control? *
Is your period regular or irregular? *
Do you experience any cramping, mood swings, or heavy clotting with your cycle? *
Date of your last Period? *
Date of your last Period?
Have you been diagnosed with any health problems such as:
Do you smoke? *
Any history of STD's ? *
Are you allergic to any medications? *
Please list who in your immediate family has been diagnosed with the following:
I have reviewed all of the above information and agree that it is correct.
Name *
Name
Birth Date
Birth Date
(and cell carrier)
Address *
Address
Effective Date *
Effective Date
Policy Holder’s Name *
Policy Holder’s Name
Birth Date *
Birth Date
Address of Policy Holder if not “self”
Address of Policy Holder if not “self”
Effective Date
Effective Date
Policy Holder’s Name
Policy Holder’s Name
Medical Records Release *
Name / Relationship / Phone
Name / Relationship / Phone
I have reviewed all of the above information and agree that it is valid and correct. *
Today's date
Today's date

After you have reviewed all of your information carefully, please click the SUBMIT button to send your form to Page, Hudson and Taylor. By clicking the "I SIGN AND AGREE" button you are electronically signing this form as if you were signing the form in person. We look forward to your visit!

Consent for Treatment: I hereby authorize the physicians, nurses, and other healthcare providers of Page ,Hudson & Taylor Gynecology to provide such medical assessment and treatment, including drugs, medications, operations and x-rays and other studies, as they deem appropriate. Authorization for release of information: I authorize Page, Hudson & Taylor Gynecology to furnish any medical information requested by insurance companies with whom I have coverage, any public agency, such as Medicare or Medicaid, if it is assisting in payment of my care, or my employer if it is providing payment of my medical bills due to anon the job injury (each a third party payor). Assignment of Benefits: I hereby assign to Page, Hudson & Taylor Gynecology or its duly authorized agents and/or assigns, all rights, benefits and interest in all proceeds from all third party payors. I authorize payment directly to Page, Hudson & Taylor Gynecology of benefits otherwise payable to me for services rendered and further authorize Page, Hudson & Taylor Gynecology to take all necessary actions to ensure that any such benefits are paid directly to Page, Hudson & Taylor Gynecology. I agree to provide and sign any other documents that may be reasonably necessary to accomplish any of the above purposed. I understand that any amount paid to Page, Hudson & Taylor Gynecology in excess of regular charges will be refunded as appropriate. Financial Responsibility: I acknowledge that I am legally responsible to Page, Hudson & Taylor Gynecology for, and I agree to pay Page, Hudson & Taylor Gynecology, all charges not paid in full by a Third Party Payor including, but not limited to, co-payments, deductibles, coinsurance and non-coverd charges. Charges remaining on this account are payable upon demand. I hereby waive all claims for exemption, including without limitation exemption from levy or execution, under the laws of the State of Alabama, and if my account is placed in the hands of a collector or attorney for collection or suit, I will pay all reasonable costs of collection fees, including reasonable attorney’s fees.