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.

Privacy Consent Form

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

Records Release Form

If you have received related care from other providers in the past, we may need to request these external medical records in order to ensure we have all relevant information to provide you the best possible care. This form will authorize us to obtain records from your other providers.

Referral Form

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

Patient Consent Form

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

Office & Privacy Policies

Office and Financial Policies

This information sheet provides you an overview of how we handle financial and procedural issues such as payments, FMLA forms, and insurance coverage for surgeries, maternity, and lab work.

Notice of Privacy Practices

Northside Women’s Health understands that your information is highly personal and we are committed to safeguarding your protected health information. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read this Notice of Privacy Practices thoroughly.