The Institute for Women's Health
  Info (210) 349 - 9300 • 

Pre-Admission

Please print out this form, fill it out, and bring it with you when you come in for your scheduled appointment.

 Confidential                              Institute For Women's Health                  Dr.________________

Acct:                                            SSN:

Phone:   (            )                             Cell:   (            )                      

Last Name:

Date of Birth:          /           /                         Age:

First Name:

Patient Employer:

Address 1:

Occupation:

Address 2:

Phone #:   (            )

City:

  Single        Married        Divorced        Widowed 

State:                       Zip:                         Country:                                    

Drivers License / ID#:

Spouse:

Religion:

PCP:

                                     Last Name                                                   First Name

Email:

Phone #:   (            )

 

Primary Insurance:

Secondary Insurance:

ID #:                                               Group:

ID #:                                               Group:

Phone:   (            )                                     Relation:

Phone:   (            )                                     Relation:

Relationship:       Self        Spouse        Child

Relationship:       Self        Spouse        Child

Social Security #:                                            DOB:

Social Security #:                                            DOB:

Employer Name:

Employer Name:

Employer Telephone:   (            )                                    

Employer Telephone:   (            )                                    

IN CASE OF AN EMERGENCY CONTACT:   (Two relatives not living with you, or friend in area).

Name:

Name:

Address:

Address:

Phone:   (            )                                     Relation:

Phone:   (            )                                     Relation:

PHARMACY INFORMATION:

Name:

Phone:  (            )

Address:

E-Mail

Fax:   (            )

 

How did you hear about the Institute For Women’s Health?

    Family       Friend       Co-worker       Insurance        Radio       Internet       Healthfair

    TV       Phonebook       Primary Care Physician       Other

Doctor or person who Refferred you: ______________________________   May we thank this person?   Yes       No 

AGREEMENTS OF BENEFITS:

I HEREBY ASSIGN ALL MEDICAL AND/OR SURGICAL BENEFITS, TO INCLUDE MAJOR MEDICAL BENEFITS TO WHICH I AM ENTITLED, INCLUDING MEDICARE, PRIVATE INSURANCE AND ANY OTHER HEALTH PLANS, TO INSTITUTE FOR WOMEN'S HEALTH. I UNDERSTAND THAT I AM RESPONSIBLE FOR SCHEDULING WITH A PARTICIPATING PHYSICIAN AND TO FOLLOW UP ON ANY DISCREPANCY IN COVERAGE WITH MY INSURANCE PLAN. I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT PAID BY MY INSURANCE. I HEREBY AUTHORIZE INSTITUTE FOR WOMEN'S HEALTH TO RELEASE ALL INFORMATION NECESSARY TO SECURE PAYMENT.

Signed: ____________________________________________________        Date: _____________________________

The Institute for Women's Health
“Our Caring Shows.”
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