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Prepare For Your Appointment

Please read the below information and fill out the forms to bring for your 1st appointment.

Whether you are self-referred to our office or are coming based on the recommendation of your provider, it is important that you bring copies of your medical records pertaining to your previous evaluation and treatments. You should call your doctor’s office prior to your appointment and ask to have your records be sent to us and have a copy of these records for your personal medical file to bring to your appointment. Before your initial evaluation, you will be asked to complete our New Patient Form, which is available to download on this page in english or spanish. Advanced completion our forms will allow us to better serve you.

DOWNLOAD NEW PATIENT FORMS - ENGLISH

DOWNLOAD NEW PATIENT FORMS - SPANISH

DOWNLOAD MEDICAL RELEASE form

MEDICAL RELEASE form

Patient Name *

First

Last

Address

Address Line 1

City

State

DOB

Social Security Number

This is my written authorization to OBTAIN/ RELEASE information TO/FROM:

Office/ Provider name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

Fax

Release Format

Mail
To Fax
to be Picked up on

to be Picked up on *

Information to be released

All Medical Records
Lab Reports
Physicians Notes
Prenatal Records
X-Ray/ Ultrasound
Hospital
Demographics
Insurance Card
Other

Other *

I understand that these records may include information on sexually transmitted diseases, AIDS, HIV, mental, health, alcohol/ drug abuse.

GDPR Agreement *

YES, I authorize the release of this information. *

GDPR Agreement *

NO, I do not authorize the release of this information. *

REVOCATION: I understand this authorization may be revoked in writing at any time. Unless otherwise indicated this authorization will expire 90 days from the date of signature. The physician and employees are released from any legal responsibility for disclosure of the above information to the extent indicated an authorized herein. I have read the above and authorized the disclosure of the protected health information as stated.

Signature of Patient/Guardian

Date

Email

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Home
Patient Services
New Patients Forms
Patient Portal
Contact Us

Home
Patient Services
New Patients Forms
Patient Portal
Contact Us

Our Promise

To provide comprehensive healthcare for women in Arizona using today’s modern technologies along with clinically proven techniques in a caring, nurturing and safe environment.

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