Forms

Please complete the appropriate forms and bring them with you to your appointment.

General

Name/Description
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Client Information Sheet

This sheet will provide our clinic with the necessary demographics neede to register you in our system. Bring your insurance card, a photo ID, and co-pay with you. Thank you.

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Medical Surgical History

One form for seeing Julie and one for seeing Paula- This form will provide the Nurse Practitioners with your history so they can give you the best comprehensive and personal care you need.

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Notice Of Privacy

This form will assure you of your privacy while receiving care from us.

OB (Obstetrics)

Name/Description
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Consent To OB Treatment

This consent gives us permission to provide prenatal, postnatal and delivery care during your pregnancy with us.

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Genetic, MSAFP, Ultrasound

These forms will give us information about your family’s genetic history. your request for the maternal serum alpha-feto protein blood screen for spinabifida, down’s syndrome and stomach wall defects. Last your request for one routine OB ultrasound done around 19 weeks pregnant.

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OB Labs List and Waiver

This form just informs you of what labs will be done in the pregnancy and offer optional ones as well.

Consents

Name/Description
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Consent to Gardasil Vaccine

If you would like to receive the Garadasil vaccine to protect against some HPV cervical cancer’s we have a consent for you to read and sign. Please see more information about HPV and cervical cancer under the INFO tab.

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Endometrial Biopsy Consent

If you need an endometrial biopsy please read and sign this consent then bring it with you to your appointment.

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IUD Insertion Device

This general IUD consent is for an insertion of either IUD contraception. Please read and sign prior to your appointment.

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Mirena IUD Consent

Please read and sign this consent specifically regarding your Mirena IUD. Then bring it with you to your appointment.

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Paragard IUD Consent

Please read and sign this consent specifically regarding your Paragard IUD. Then bring it with you to your appointment.

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