Annual paperwork

Women's Wellness Center

645 Sierra Rose Drive # 204 Reno, NV 89511 Phone (775)-352-9355 Fax (775)-352-3575
Patient Demographic Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security #
Marital Status
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Number*

Area CodePhone Number
Secondary Number

Area CodePhone Number
Email
example@example.com
Employer
Employer
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Responsible Party Name (if patient is a minor)
Do you have active insurance?*

YesNo, I will be cash pay
If you have insurance, please fill out below fields and bring your insurance card to your visit. There are some insurance plans we do not accept, please confirm your plan with our office, before your appointment.
Primary Insurance Company
Policy Holder
Insurance ID #
Secondary Insurance Company
Policy Holder
Insurance ID#
Primary Care Physician
Referring Physician
Laboratory, Radiology, & Pharmacy
Pap smears will be sent to Aurora Laboratory, unless insurance is through Anthem - Aurora accepts all other insurance plans.
Preferred Lab for blood work *
For radiology services, such as ultrasounds and mammograms, I prefer to use *
Other preferred radiology facility (if not listed)
I am aware that I am responsible for knowing my preferred lab and radilogy facility. I will be responsible for any charges incurred that my insurance may not cover.
Pharmacy*
Location
Street
Do you have an Advance Directive (Living Will)?*
Please be advised, if you are over 40, a Fecal Occult Blood (FOB) test will be performed during your annual exam in order to test for blood in your stool. This test may or may not be covered by insurance and the total cost is $28.00.

Release of Protected Health Information
If you want your medical information shared with another person (spouse, parent/guardian, or relative) they must be listed on this form in order for us to share any information. This applies to minors as well. We will not share any health information without consent.
I, First Name Last Name give Women's Wellness Center permission to share my protected health information with First Name Last Name- relationship to patient .

If you do not wish to have any of your health information shared with anyone, please type declined here: This applies to minors as well.
Do you give Women's Wellness Center permission to share your protected health information with your Primary Care Physician?*
Name of Primary Care Physician First Name Last Name
This authorization is in effect for one year from date signed.

Interval History

Please help keep us up to date by answering the following questions:
Name*

First NameLast Name
Physicians other than Primary Care you see:
Name
Name
Have you had any serious illnesses, operations, injuries, or have you been hospitalized since your last visit to our office?*

YesNo
If yes, please list
Have you discovered any additional information about your family history that we should know? (i.e. - cancer, heart, etc.)*

YesNo
If yes, please list
Have you had changes in your medications or birth control since your last visit?*

YesNo
If yes, list new and/or discontinued medications:
Have you changed any habits (smoking, drinking, drug use) or occupation since your last visit?*

YesNo
If yes, please explain:

Women's Wellness Center

Cancellation Policy
Due to an increase in missed appointments, we are reminding patients that we require 24 hours notice for canceling or rescheduling appointments. We will be charging a $50 no call/no show fee for patients who fail to give 24 hours notice. We strive to provide excellent care for our patients and often have patients that need to be seen for an urgent issue. When a patient fails to notify our office of their cancellation, their appointment time, that could have been used to help another patient, is lost.

We value our patients' time and therefore, request that patients check in on time. Out of respect for other scheduled patients, late patients may need to reschedule.

I have read the above policy and understand that if I fail to provide 24 hours notice for canceling or rescheduling an appointment, I will be charged a $50.00 fee. No call/No show fees will need to be paid prior to scheduling another appointment.
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Women's Wellness Center

Patient Demographic Form

Laboratory, Radiology, & Pharmacy

Release of Protected Health Information

Interval History

Review of Systems

Women's Wellness Center