Elite Women's Care
Patient Demographics
Patient's Legal Name
Patient Information
Health History
Medical History: (please select Yes or No)
GYN History: (please select Yes or No)
Pregnancy History: (please select Yes or No)
Surgical History:
Family History:
Social History:
HIPAA Consent
Messages From Our Office and/or Appointment Reminders
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.
I have read, filled out and agree to all of the above.
General Consent for Care and Treatment
Pelvic Examinations Consent Form
*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.