Sign up to receive GTW's free monthly email newsletter filled with health tips, classes, events and more!

patient forms

Paperwork must be completed and returned in advance of the appointment in order to assure that our physicians have adequate time to spend with their patients.  Please mail or fax completed paperwork to the office address and fax noted above.

PATIENT INFORMATION (INFORMATION, POLICIES, AND HISTORY)

• MUST BE COMPLETED ANNUALLY

• REQUIRED FOR ALL NEW PATIENTS & ALL ANNUAL/SCHOOL/CAMP PHYSICALS

WE THANK YOU FOR UNDERSTANDING THAT MOST INSURANCE COMPANIES DO NOT PAY FOR ADDRESSING PROBLEMS AND FOR PREVENTIVE / WELLNESS CARE PROVIDED ON THE SAME DAY.  THE PATIENT IS RESPONSIBLE FOR ADDITIONAL FEES IF THIS APPLIES.  PLEASE LET US KNOW IF YOU WOULD LIKE TO SCHEDULE A SEPARATE APPOINTMENT ON A DIFFERENT DAY TO BETTER MEET YOUR NEEDS.

RECORD RELEASE ( REQUEST / RELEASE RECORDS TO OR FROM OTHER PROVIDERS)

Complete for previous primary care, specialists, and mental health providers as appropriate. 

opyright 2009 Girls To Women, P.A. | privacy policy | fact sources | forms