Pre-visit Registration Form

MM/DD/YYYY
First
Last
MM/DD/YYYY
(Other than Spouse):

Employment Information

Insurance Information

Patient Health History

Please indicate YES if you have any of the following conditions:

Gynecological History

Pregnancy History

Family History (Anyone in your family)

Birth Control

Include vasectomy or tubualiagtion

Women Having Periods

(day one of your cycle to day one of the next)
(start of cycle to end of cycle)

For Everyone

Breast Health

General Information

By typing my name in the above box I certify that the above information is true and correct to the best of my knowledge, and hereby authorize payment of medical benefits billed to my insurance to Progressive Women’s Healthcare, P.C. I hereby accept responsibility for payment for any service(s) provided to me that is not covered by my insurance. I also accept responsibility for fees that exceed the payment made by my insurance, if the practice does not participate with my insurance. I also agree to pay ALL co-payments, coinsurances, and deductibles at the time the service is rendered. I also authorize the practice to release any information required to process my claims.
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