Gynecological & Obstetric Associates


PATIENT
INFORMATION FORM

Is this a name change since your last visit?   
Marital Status   
Do you have healthcare insurance?   
I hereby authorize release of any treatment information necessary to process my insurance claim. I authorize payment of any benefits directly to my physician.

I understand that I am responsible for paying any or all balance(s) on my account for services rendered. I have received a copy of the Financial Policy.
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.
 
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