Appointment
Visit Questionnaires – McKINNEY

FOR SCHEDULED PATIENT VISITS ONLY*  (forms work best on laptop or tablet)

Please complete appropriate forms the SAME DAY as (no sooner than 24 hours before) your scheduled appointment in order to give us the most current information. Depending on the concern or situation, you may need to complete forms from multiple sections.

Please be advised that by providing this form for you to contact our office(s), we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into this portal. Our office will follow up with you within 24 to 48 business hours.  Please note: We may not see submitted forms for 24 hours depending on when the forms were completed.  For any safety concerns, thoughts of self-harm or suicide, or severe medical symptoms please call 911 for medical emergencies or text “help” to 741-741 or call the National Suicide Hotline at 1-800-273-8255, https://suicidepreventionlifeline.org/

*Not intended for use by the general public but only for patients with scheduled appointments.

 

PARENT INPUT (welcome and encouraged for patients of all ages)

For all new visits, annual exams, mental health/nutrition health assessments and updates.

 

NEW PATIENT APPOINTMENTS & ANNUAL WELLNESS (for NEW or ESTABLISHED patients)

Complete both Part 1) Medical History  & Part 2) Patient Survey

Annual Practice Consent (under 18)

Annual Practice Consent (18 and older)

Medical Record Release (Consent to Obtain/Share Protected Health Information)

SICK VISITS

Provide details of current acute illness complaints.

 

OTHER MEDICAL PROBLEM VISITS

Provide details of non-acute, recurrent, or chronic conditions.

 

MENTAL HEALTH

Complete Mental Health History for new patient mental health evaluation or new concern in established patient. Complete Patient Symptom Report for both new and/or follow up appointments for mental health concerns.

 

NUTRITION-BODY IMAGE

Add to Mental Health forms if concerns about nutrition patterns, body image, or eating disorders.

 

 

 

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FOR OFFICE USE ONLY / BY INSTRUCTION ONLY

Nexplanon w/ Benefits Investigation Consent 

Mirena/Skyla Benefits Investigation Consent

©2019 Girls to Women Health & Wellness
16980 Dallas Pkwy 75248 Dallas, United States P: (972) 733-6565
4200 S. Hulen Street, Suite 450, Fort Worth, Texas 76109 P: (817) 524-1811
Fax: (972) 733-6564

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