Forms to Complete Before Your Appointment

Patient Demographics Form

Please complete and bring this Patient Demographics Form to your first appointment, along with your insurance card, which will help make your office visit as smooth as possible.

Patient Medical History Form

Please complete and bring this Patient Medical History Form to your first appointment, along with your insurance card, which will help make your office visit as smooth as possible.

Authorization and Consent for Treatment

All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility.

Authorization for Release of Medical Information

Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Referral Form

If you are being referred to our office by another physician, please have your physician complete and fax this form to us.

Preferred Contacts

Patients are encouraged to complete and return the Preferred Contacts Form but it is not required.

Office & Privacy Policies

Financial Policies

This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.

Notice of Privacy Practices

Describes how health information about you (as a patient of Northside Women’s Health) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

Please fill out this additional form only if you are being seen for perimenopausal or menopausal symptoms, or hormone replacement therapy.