Wise Obstetrics & Gynecology, PA


New Patient Packet

 
Patient Information
Marital Status
Person Responsible for Payment
Is Patient the Person Responsible?
Medical Insurance Info
Do you have healthcare insurance? 

Emergency Contact
Financial Responsibility Statement
I hereby authorize my insurance benefits to be paid directly to Renee Smith, MD, understanding that if my services are not covered by my insurance, I may be responsible to pay. If I do not have insurance and am private pay, I understand that I am responsible for payment at time services are rendered.
Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Wise Obstetrics & Gynecology, PA


Review of Systems

 
Gynecological Intake History
Please check the appropriate box if any of the following apply to you now or have applied in the past
CONSTITUTIONAL
  Weight Loss
  Weight Gain
  Fever
  Fatigue
EYES
  Double Vision
  Spots Before Eyes
  Vision Changes
ENT/MOUTH
  Earaches
  Ringing in Ears
  Sinus Problems
  Sore Throat
  Mouth Sores
  Dental Problems
CARDIOVASCULAR
  Painful Breathing
  Chest Pain
  Difficulty Breathing on Exertion
  Swelling of Legs
  Palpitations of Heart
RESPIRATORY
  Wheezing
  Spitting Up Blood
  Shortness of Breath
  Chronic Cough
GASTROINTESTINAL
  Frequent Diarrhea
  Blood in Stool
  Nausea/Vomiting
  Constipation
GENITOURINARY
  Blood in Urine
  Pain with Urination
  Urgency
  Frequency of Urination
  Incomplete Emptying
  Stress Incontinence
  Abnormal Periods
  Painful Intercourse
MUSCULOSKETAL
  Muscle Weakness
SKIN/BREAST
  Pain in Breast
  Breast Discharge
  Breast Masses
  Rash
  Ulcers
NEUROLOGICAL
  Dizziness
  Seizures
  Numbness
  Trouble Walking
PSYCHIATRIC
  Depression
  Frequent Crying
ENDOCRINE
  Dry Skin
  Abnormal Thirst
  Hot Flashes
HEMOTOLOGIC/LYMPHATIC
  Frequent Bruising
  Cuts that Won't Stop Bleeding
Current Medications
(Dosage example: “10 mg.” –  How Taken example: “1 tablet daily”)
        

Add another medication?
Immunizations
Personal Safety
Has anyone close to you ever threatened to hurt you?  
Has anyone ever hit, kicked, choked or hurt you physically?  
Has anyone, including your partner, ever forced you to have sex?  
Are you afraid of your partner?  
Have you been treated for any of the following infections?






Have you had a Pap Smear in the last 7 years?  
Have you ever had an abnormal Pap Smear test?  
Have you ever tested POSITIVE for the HIV virus?  
Did your mother take the drug DES when she was pregnant with you?  
Family Cancer History
Please check the appropriate box if any family member has had any cancer type, including their relationship to the patient (including maternal/paternal side)
Is there any known family hereditary cancer syndrome?
Was this page completed by:

Signature of Patient or Legal Guardian – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Wise Obstetrics & Gynecology, PA


Notice of Patient Rights and Responsibilities

 
This document is meant to inform our patients of their rights and responsibilities while they are undergoing medical care. To the extent permitted by law, patient rights may be delineated on behalf of the patient to his or her guardian, next of kin, or legally authorized responsible person if the patient: a) has been adjudicated incompetent in accordance with the law, b) is found to be medically incapable of understanding the proposed treatment or procedure, c) is unable to communicate his or her wishes regarding treatment, or d) is a minor. If there are any questions regarding the contents of this notice, please notify any staff member.
Patient Rights
  1. Access to Care. You will be provided with impartial access to treatment and services within this practice’s capacity and availability and in keeping with applicable laws and regulations. This is true regardless of race, creed, sex, national origin, religion, disability or handicap.
  2. Respect and Dignity. You have the right to considerate, respectful care and services at all times and under all circumstances. This includes recognition of psychosocial, spiritual, and cultural variables that may influence the perception of your illness.
  3. Privacy and Confidentiality. You have the right, within the law, to personal and informational privacy. This includes the right to:
    • Be interviewed and examined in surroundings that ensure reasonable privacy
    • Have a person of your own sex present during a physical examination or treatment
    • Not remain disrobed any longer than is required for accomplishing treatment or services
    • Request transfer to another treatment room if a visitor is unreasonably disturbing
    • Expect that any discussion or consultation regarding care will be conducted discreetly
    • Expect all written communications pertaining to care to be treated as confidential
    • Expect medical records to be read only by individuals directly involved in care, quality-assurance activities, or the processing of insurance claims. No other persons will have access without your written authorization.
  4. Personal Safety. You have the right to expect reasonable safety regarding the practice’s procedures and environment.
  5. Identity. You have the right to know the identity and professional status of any person providing services and which physician or other practitioner is primarily responsible for your care.
  6. Information. You have the right to obtain complete and current information concerning your diagnosis (to the degree known), your treatment, and any known prognosis. This information should be communicated in terms that you understand.
  7. Communication. If you do not speak or understand the predominant language of the community, you should have access to an interpreter. This is particularly true when language barriers are a continuing problem.
  8. Consent. You have the right to information that enables you, in collaboration with the physician, to make treatment decisions.
    • Consent discussions will include an explanation of the condition, the risks and benefits of treatment, as well as the consequences of no treatment.
    • Except in the case of incapacity or life-threatening emergency, you will not be subjected to any procedure unless you provide voluntary, written consent.
    • You will be informed if the practice proposes to engage in research or experimental projects affecting its care or services. If it is your decision not to take part, you will continue to receive the most effective care the practice otherwise provides.
  9. Consultation. You have the right to accept or refuse medical care to the extent permitted by law. However, if refusing treatment prevents the practice from providing appropriate care in accordance with ethical and professional standards, your relationship with this practice may be terminated upon reasonable notice.
  10. Charges. Regardless of the source of payment for care provided, you have the right to request and receive itemized and detailed explanations of any billed services.
  11. Rules and Regulations. You will be informed of the practice’s rules and regulations concerning your conduct as a patient at this facility. You are further entitled to information about the initiation, review, and resolution of patient complaints.
Patient Responsibilities
  1. Keep Us Accurately Informed. You have the responsibility to provide, to the best of your knowledge, accurate and complete information about your present complaints, past illnesses, hospitalizations, medications, and other matters relating to your health, including unexpected changes in your condition. You also have the responsibility to keep your contact information up to date, so we can contact you if needed.
  2. Follow Your Treatment Plan. You are responsible for following the treatment plan recommended by the physician. This may include following the instructions of health care personnel as they carry out the coordinated plan of care, implement the physician’s orders, and enforce the applicable practice rules and regulations.
  3. Keep Your Appointments. You are responsible for keeping appointments and, when unable to do so for any reason, for notifying this practice. The consequence of missing three consecutive appointments can be termination of your relationship with this practice.  You may be charged a fee for missed appointments.
  4. Take Responsibility for Noncompliance. You are responsible for your actions if you do not follow the physician’s instructions. If you cannot follow through with the prescribed treatment plan, you are responsible for informing the physician.
  5. Be Responsible for Your Financial Obligations. You are responsible for ensuring that the financial obligations of health care services are fulfilled as promptly as possible and for providing up-to-date insurance information.
  6. Be Considerate of Others. You are responsible for being considerate of the rights of other patients and personnel and for assisting in the control of noise, smoking, and the number of visitors. You also are responsible for being respectful of practice property and property of other persons visiting the practice.
  7. Be Responsible for Lifestyle Choices. Your health depends not just on the care provided at this facility but on the long-term decisions you make in daily life. You are responsible for recognizing the effects of these decisions on your health.
  8. The after hours line is for emergency use only.  Abuse of this can also result in a fee.
Wise Obstetrics & Gynecology, PA


Notice of Privacy Practices

 
Would you like to read our Notice of Privacy Practices?
Wise Obstetrics & Gynecology, PA


Notice of Privacy Practices Acknowledgement

 
I acknowledge that Wise Obstetrics & Gynecology offered to provide me with a written copy of their Notice of Privacy Practices.

I also acknowledge that I have been afforded the opportunity to read the Notice of Privacy Practices and ask questions.
Signature of Patient – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Personal Representative Signature (if applicable) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Wise Obstetrics & Gynecology, PA


Patient Consent to Treat

 

I hereby give my consent to Wise Obstetrics & Gynecology and authorize him or her to provide my medical treatment. I understand that Wise Obstetrics & Gynecology will explain my condition(s), foreseeable risks, and methods of treatment for my condition before treatment is provided. I authorize Wise Obstetrics & Gynecology to perform any additional or different treatment that is thought necessary if, in an emergency situation, a condition is discovered that was not known previously.

I understand that payment is due at the time services are provided. Pre-payment is required for non-emergent surgery and delivery care. I understand that I may be charged a fee for non-emergent use of after-hours phone line. I have carefully read and I fully understand this Patient Consent to Treat form and have had the opportunity to discuss my condition and the above procedure(s) with the care provider. All my questions have been adequately answered.
 
Signature of Patient – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Parent or Legal Guardian Signature (for minor) – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
 
Note: Please have your legal counsel review this form before using it.
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