Patient Forms - Elite Women's Care

Elite Women's Care

Patient Demographics

Patient's Legal Name

Last *

First *

Middle

Gender: *

Mailing Address *

Include City, State, and Zip Code

Street Address

Include City, State, and Zip Code

Home Phone:

Include Area Code

Cell Phone: *

Include Area Code

Email *

Date of Birth: *

Social Security Number:

Current Marital Status *

Choose One

Living Will: *

Primary Care Provider: *

Spouse's Name:

Spouse's Date of Birth

Spouse's SSN:

If insured through spouse

Emergency Notification: *

Not Living In Same Household

Emergency Notification Phone: *

Include Area Code

Responsible Party Relationship to Patient *

Relationship to Patient *

Responsible Party Phone Number: *

Include Area Code

Responsible Party Date of Birth: *

Social Security Number:

Mailing Address

Include City, State, and Zip Code

Street Address

Include City, State, and Zip Code

Patient Information

Race: *

Ethnicity: *

Language: *

Employment Status: *

Patient Employer *

Patient Work Phone:

Include Area Code

Student Status: *

Pharmacy Name: *

Pharmacy Address or Cross Street: *

Pharmacy Phone Number:

How Did You Hear About Our Office? *

Health History

Reason For Visit *

Medications/Herbals or Vitamins: : ( name, dosage and directions-feel free to attach a separate list) *

Allergies: Medication/Environmental/Food (If Yes, please specify medication and reaction) *

Medical History: (please select Yes or No)

Cancer *

Type of Cancer

Asthma/Lung Disease *

Hypertension *

Bleeding/Clotting Disorder *

Diabetes *

Autoimmune Disorder *

Psychological Disorder *

Stroke *

High Cholesterol *

Tuberculosis *

Osteopenia/Osteoporosis *

Neurological Disorder *

Heart Disease/Attack *

Thyroid Disorder *

Hepatitis/Liver Disease *

Other:

If you answered yes to any of the above questions, please explain. Include date, treatment received and if available, physician treating the condition:

Have you had a blood transfusion? *

If yes: When?

GYN History: (please select Yes or No)

Date of Last Pap * Date of Last Pap

Normal or Abnormal *

History of Abnormal Pap Smears: *

HPV vaccine: *

Length of periods (days): *

Number of days between periods: *

Sexually active: *

Your partner(s): *

Date of last mammogram: * Date of last mammogram:

Mammogram Normal/Abnormal: *

Date of bone density:

Bone Density Normal/Abnormal:

How do you prevent pregnancy:

Age of first period: *

Age at onset of menopause:

Last menstrual period:

History of STD's

Pregnancy History: (please select Yes or No)

# of pregnancies: *

# of miscarriages: *

# of abortions: *

# of C-Sections: *

# of Living Children: *

Surgical History:

Surgical History: (what type of surgery and when) *

If none, please use the answer none

Date of Last Colonoscopy:

Hospitalizations: (which hospital, when and the reason for admission/ER visit) *

If none, please use the answer none

If over 65, have you fallen in the past year? If so, what caused the fall(s) (such as dizziness, related to medication, low blood sugar, tripped, etc.)?

Family History:

Breast Cancer

Maternal / Paternal

Family Member Family Member

Ovarian Cancer

Maternal / Paternal

Family Member Family Member

Uterine Cancer

Maternal / Paternal

Family Member Family Member

Colon Cancer

Maternal / Paternal

Family Member Family Member

Osteoporosis

Maternal / Paternal

Family Member Family Member

Pancreatic Cancer

Maternal / Paternal

Family Member Family Member

Other

Maternal / Paternal

Family Member Family Member

Social History:

Caffeine (drinks or caffeine containing drugs) *

If Yes: How Much? *

Tobacco *

If Yes: How much per day? *

How long used? *

Alcohol *

If Yes: How much per day? *

How long used? *

Drug Use (illicit or non-prescribed) *

If Yes: How often? *

What Type? *

Domestic Abuse *

If yes: Past or Present *

Specialists: (name of physician and condition treated)

Today's Date *

Patient (or Responsible Party) Signature: *

Clear

HIPAA Consent

I understand that as part of my healthcare, Elite Women’s Care, originates and maintains paper and/or electronic records describing my
health history, symptoms, examination and test results, diagnoses, treatment and any plans for future treatment. I understand that this
information serves as:

A Basis for planning my care and treatment;
A means for communication among health professionals who contribute to my care, such as referrals;
A source of information for applying my diagnosis and treatment information to my bill;
A means by which a third-party payer can verify that services billed were actually rendered;
A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff.

I understand that as part of treatment, payment or healthcare operations, it may become necessary to disclose health information to
another entity, i.e. referrals to other healthcare providers. I consent to such disclosure for these uses as permitted by law. I fully
understand and

Select One *

accept

decline this consent.

Notice of Privacy Practices
I acknowledge that I have been informed of Elite Women’s Care Notice of Privacy Practices that provides a description of our practice’s uses and
disclosures of Protected Health Information. I understand that I have the right to review the Notice of Privacy Practices and receive a copy before signing
this statement. I understand that Elite Women’s Care has the right to change its Notice of Privacy Practices that will be effective for health information
Elite Women’s Care already has about me, as well as any they receive in the future. Elite Women’s Care has posted a current copy of the Notice of
Privacy Practices in our lobby for review. I understand that I may obtain a copy of the current Notice in effect upon request. I have read all of the above
and understand/agree to all the provisions therein regarding responsibility for payment, permission for treatment and Notice of Privacy Practices.

Requesting Medical Records From Our Office
Our office requires patients and their representatives to sign an Authorization Form before release of medical records.

Messages From Our Office and/or Appointment Reminders

May we leave a message at your home using doctor’s/practice name?

Phone #/Email to Use

May we leave a message at your work using doctor’s/practice name?

Phone #/Email to Use

May we text you appointment reminders and other messages?

Phone #/Email to Use

May we email you appointment reminders and other messages?

Phone #/Email to Use

Please list all family members or other person(s), if any, whom we may disclose your protected health information, including treatment and payment information. These persons will have full access to your protected health information.

Name

Phone Number

Name

Phone Number

Name

Phone Number

I have read, filled out and agree to all of the above.

Patient/Guardian Signature: *

Clear

Patient Name if Different:

Printed Name *

Date *

If other than the patient is signing, are you the legal guardian, custodian or have Power of Attorney for this patient for payment, treatment or healthcare operations? *

Yes

No

General Consent for Care and Treatment

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid-level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination including but not limited to pelvic examination, testing and other treatment for the condition which has brought me to seek care at
this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Signature of Patient or Personal Representative *

Clear

Date *

Printed Name of Patient or Personal Representative *

Relationship to Patient

Printed Name of Witness

Employee Job Title

Signature of Witness

Clear

Date

Pelvic Examinations Consent Form

Patient Name: *

Date of Birth: *

CONSENT: I, the above listed Patient or as the legally authorized person for the Patient, hereby consent to receiving pelvic examinations being performed by my physician or other health care practitioner, any medical student or any student receiving training as a health care practitioner.

NATURE OF PELVIC EXAMINATIONS
For the purposes of this Consent Form, a “pelvic examination” on a female means the series of tasks that comprise
an examination of the vagina, cervix, uterus, fallopian tubes, ovaries, rectum, or external pelvic tissue or organs using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation.

For purposes of the Consent Form, a “pelvic examination” on a male means examination of the rectum, prostate, and
external tissue or organs, including the penis or scrotum using any combination of modalities, which may include, but need not be limited to, the health care provider’s gloved hand or instrumentation.

I CONSENT TO RECEIVE PELVIC EXAMINATIONS AS DESCRIBED ABOVE, AND ALL MY QUESTIONS HAVE BEEN ANSWERED TO MY SATISFACTION.

Patient’s Signature *

Clear

Date *

Legally Authorized Person Signature

Clear

Relationship to Patient

Legally Authorized Person Printed Name

Date

Witness Signature

Clear

Witness Printed Name

Date

*Due to Senate Bill 698 that was recently signed by the Governor, a separate consent for pelvic examination is required for all patients being seen in the office IN ADDITION TO the consent to treat that is already required.

reCAPTCHA