♟Women's Health | New Patient Registration

Personalized Care ♟ Women's Health

Let's get to know you...in private.
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Submission Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Patient Gender (at birth)*
Patient E-Mail*
example@example.com
Address: Please list the location you would like a service at. *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Appointment
Phone Number*

Country CodeArea CodePhone Number
Preferred Method of Contact

EmailTextGood Old Fashioned Phone Call
I'm here for a Women's Health consultation or concern.*

YesNo
Please briefly describe the reason for your women's health appointment:
Please check all that apply. I am looking to schedule the following:*

Annual Well-Woman ExamAt-Home Physical AssessmentPAP SmearPelvic Exam/Breast ExamPregnancy/FertilityBirth ControlSTI/STD TestingDiagnostic Testing (ie: EKG, ECHO, MRI, CT Scan or Ultrasound Test)Other (not listed here)I'm not sure and need help figuring out what's needed.
Are you currently pregnant?

YesNoThere is a possibility that I could be pregnant.
Are you currently under the care of a OB-GYN?

YesNo
If yes, please tell us the name and telephone number of your OB-GYN:
Please upload any orders or forms from your medical doctor:

Cancelof
Why cover the whole bill if you don't have to? Upload the front and back of your insurance card here and we can see what we can get comped for you :)

Cancelof
We want to put a face to your name. Please upload the front and back of your government-issued ID here:

Cancelof
Medical History

We care about you...
Have you ever had (Please check all that apply)

AnemiaAsthmaArthritisCancerGoutDiabetesEmotional DisorderEpilepsy SeizuresFainting SpellsGallstonesHeart DiseaseHeart AttackRheumatic FeverHigh Blood PressureDigestive ProblemsUlcerative ColitisUlcer DiseaseHepatitisKidney DiseaseLiver DiseaseSleep ApneaUse a C-PAP machineThyroid ProblemsTuberculosisVenereal DiseaseNeurological DisordersBleeding DisordersLung DiseaseEmphysema
Other illnesses:
Do you have any allergies?*

YesNo
Please list your allergies:
Please list your Current Medications:
Please list Surgical Procedures & Dates of Each:
Healthy & Unhealthy Habits

No judgements, offering improvements upon request...
Exercise

Never1-2 days3-4 days5+ days
Eating habits/following a diet

I have a loose dietI have a strict dietI eat generally healthy, but I could make improvementsI don't have a diet plan
Alcohol Consumption

I don't drinkI am a social drinker (less than 5 drinks/week)1-2 glasses/day3-4 glasses/day5+ glasses/day
Do you smoke?

No0-1 pack/day1-2 packs/day2+ packs/day
Do you Vape?

YesNo
Are there any other elements or substances in your routine?

CaffeineMarijuanaMagic MushroomsCocaineMDMA and/or 2CBLSDMethamphetamineOther
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION TO THIRD PARTY PURSUANT TO HIPAA

This authorization indicates a disclosure of information pertaining to medical records and the release of official laboratory results/treatment to a third party for the intended medical reasons. I, the patient, allow Checkmate Health Strategies to release any/all results and reports in relation to my women's healthcare plan to my OB-GYN, primary care physician/medical doctor, surgeon, and/or the affiliates involved in my care.

I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form to only those agreed upon for the my care.
CHECKMATE HEALTH STRATEGIES AUTHORIZATION TO GIVE MEDICAL CARE – CONSENT TO TREATMENT: I hereby voluntarily consent to treatment and care from all medical personnel contracted with Checkmate Health Strategies. I further consent to the performance of any diagnostic procedures, examinations, laboratory tests and rendering of medical treatment by Checkmate Health Strategies’ medical Providers and staff, as is necessary in the medical staff’s judgment. I understand that this consent will be valid and remain in effect as long as I am a patient at the clinic. *

Clear
Date

MonthDayYear
Date

Booking Deposit Payment*

Deposit (Women's Health)Non-Refundable. Pay remainder at time of booking.

$75.00

Enter coupon

Total

$0.00

Should be Empty:

Personalized Care ♟ Women's Health

Medical History

Healthy & Unhealthy Habits