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.
1. I understand that if I do not pay my account with Women's Wellness Center in full, my account may be assigned to a collection agency for collection.
2. I understand that if my account is assigned to a collection agency, the collection agency will charge a commission or fee that may be as much as 50% of the amount I owe to Women's Wellness Center. I agree that if my account is assigned to a collection agency, Women's Wellness Center may add the amount of the collection agency's comission or fee to the amount I owe to Women's Wellness Center and I agree to pay the additional amount.
3. I understand and agree that in the event, legal action is commenced to enforce my obligations, I will pay court costs and attorney's fees.
*Please note that hiring a collection agency, should your account be delinquent, is the last alternative made by the billing department. The billing department is very attentive in giving ample notice before an account is sent to collections. Furthermore, options for payment plans are available when approriate. Should this payment plan be neglected, a warning notice will be sent prior to involving a collection agency. Refusing to sign this agreement will not prevent delinquent accounts from being sent to collections.
I, First Name Last Name have reviewed or have access to, the Notice of Privacy Practices for Women's Wellness Center. (located on Web Site)
Pap smears will be sent to Aurora Laboratory, unless insurance is through Anthem - Aurora accepts all other insurance plans.
I am aware that I am responsible for knowing my preferred lab. I will be responsible for any charges incurred that my insurance may not cover.
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.
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.
Name of Primary Care Physician First Name Last Name
This authorization is in effect for one year from date signed.
Age at first menstrual period Number of days in cycle Number of period days
HPV Vaccination 1st Date 2nd Date 3rd Date
Age of menopause Bleeding after menopause Please SelectYesNo
Pregnancies Number* Normal Vaginal Deliveries Number C-Sections Number Miscarriages Number Abortions Number Living Children Number Complication:
Surgery/Reason for Hospitalization Date DateSurgery/Reason for Hospitalization Date Date Surgery/Reason for Hospitalization Date Date Surgery/Reason for Hospitalization Date Date Surgery/Reason for Hospitalization Date Date Surgery/Reason for Hospitalization Date Date
Diabetes Please SelectYesNo* Relative Stroke Please SelectYesNo* Relative Heart Disease Please SelectYes No* Relative High Blood Pressure Please SelectYesNo* Relative Osteoporosis Please SelectYesNo* Relative Thyroid Disease Please SelectYesNo* Relative Drinking Problem Please Select YesNo* Relative Breast Cancer Please SelectYesNo* Relative Colon Cancer Please SelectYesNo* Relative Ovarian Cancer Please SelectYesNo* Relative Uterine Cancer Please SelectYesNo* Relative
Number of living children and ages: Number* Number Number Number Number Number
Number of people in household:
Current or most recent job:
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.