New Patient History & Physical
Name
Social Security #
Date of Birth
Street
Apt# Phone
City State Zip
Email
Race Language
Emergency Contact Phone
Primary Care Physician
Phone
Preferred Pharmacy
Phone
Dates of:
First day of Last Period
Last PAP
Last Bone Density
Last Mammogram
Other:
Birth Control Method
History of STD/ Type
History of Abnormal PAP
Medications:
Allergies:
Additional Notes:
Pregnancy History:
Lifestyle:
Do you Exercise?
Use Tobacco?
Drink Alcohol?
Street drugs?
How Often?
Cigarettes/day?
How often and what kind?
Last Used?
How many years?
Childs Name:
Dates of: Miscarriage
Still Birth
Ectopic
Abortion
Birth
Date:
Week's
Gestation:
Type of
Birth:
Birth
Weight:
Pregnancy
Complications:
Delivery
Complications:
Surgery History: Surgery Dates:
Are Antibiotics Required Before Surgery? YES NO
Conditions/ Reason:
NAME:
DATE OF BIRTH:
Everyday, we’re learning how much a person’s background can affect their own health, particularly if there’s
a history of cancer in the family. Family history is important because we know people can inherit an
abnormal gene that can affect their risk for developing cancer.
Your answers to the questions below can help us determine if you may have a chance of having an inherited
risk of certain cancers
Please consider your immediate family as well as grandparents, aunts, uncles and cousins
If you have a checkmark for any of the above responses, please turn this page over and write out the information about your
family cancer history on the back. You can Share this with your doctor and talk about your cancer risk
Note* This form is for information purposes only. Ultimately, you and your doctor will determine the best course of action
based on the information you have provided. by answering “No” to all of the above questions does not eliminate risk for
hereditary or other cancers.
National* guidelines recommend that individuals with Ashkenazi Jewish (AJ) heritage and a family history of breast, ovarian
or pancreatic cancer consider genetic testing. However, some studies suggest that testing individuals of AJ heritage regardless
of their personal family history may be beneficial.
New Patient History & Physical
Please Complete this form (Please check all that apply) Past Medical
History for Patient and Family, Please list if Grandparent, Aunt, Uncle is Maternal or Paternal.
Disease Condition Self Mother Father Grandmother Grandfather Sister
Brother
Aunt Uncle
Anemia
Asthma
Breast Cancer
Cervical Cancer
Bleeding Disorder
Colon Cancer
Heart Disease
Diabetes
Genetic Disorder
Hepatitis
High Cholesterol
High Blood Pressure
Infertility
Lung Cancer
Ovarian Cancer
Ovarian Cyst
Polycystic Ovary Syndrome
Prolapsed Uterus
Psychiatric Disease
Pulmonary Embolism
Seizure Disorder
Thyroid Disease
Other
Uterine Cancer
Tuberculosis
Patient Responsibility Notice
Thank you for choosing Wildflower Women’s Center for your obstetrical and /or
gynecological care. We are committed to providing you with the highest quality healthcare.
We ask that you read and sign this form to acknowledge your understanding of our patient
financial policies.
Patient Financial Responsibilities
The patient (or patients guardian, if a minor) is ultimately responsible for the payment of
treatment and care.
We’ll bill your insurance for you. However, the patient is required to provide us with the
most current and correct insurance and billing information
Co-payments are due at the time of service.
We are a specialist. However, since most insurance companies consider us primary
care, we collect the primary care physician co-payments as a specialist co-payment, we
will bill you for the difference.
We accept most insurance plans. We highly recommend contacting your insurance company
to see if the physician providing care is in your insurance network. Failure to do so could
result in being billed for todays visit.
if your Insurance company requires you to use a specific laboratory, please tell the
rooming assistant
Most insurance companies will only cover one preventive exam per calendar year. If it has
not been a complete year or you have seen a different provider for preventive services
within the past year, you could be responsible for payment of preventive services.
Print Name:______________________________________Date:________________________
Patient Signature:______________________________________________________________
Tina Gingrich, MD
3122 Milrany Ln. Melissa, TX 75454
(214) 295-8675
Wildflowerwomenscenter.com
coinsurance, deductibles and non-covered services should be paid in full within 60 days of
the services that were provided.
There is a charge for missed or same day cancellation, without 24-hr notice.
Missed appointment fee for an office visit is $25.00
Missed appointment fee for and ultrasound visit is $50.00
RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, ________________________________ hereby acknowledge receipt of Wildflower Women’s Center
Notice of Privacy Practices.
The Notice OF PRIVACY PRACTICES provides detailed information about how Wildflower
Women’s Center may use and disclose my confidential information. I have been offered a paper
copy of NOTICE OF PRIVACY PRACTICES. I understand that WILDFLOWER WOMEN’S
CENTER has reserved a right to change the
privacy practice that are described in the Notice. I also understand that a copy of any revised
Notice will be provided to me or made available. Copies of the most current NOTICE OF PRIVACY
PRACTICES are posted at the front desk. I
understand that I may request a paper copy at any time.
Print Name ___________________________________ Date of Birth ______________________________
Signature _____________________________________ Date __________________________
If you are not the patient, please specify your relationship to the patient below:
__________________________________________________________________________________
CONSENT TO TEXT & EMAIL PATIENT
At Wildflower Women’s Center we want to get results to you quickly. Our secure portal is the
most efficient way to do this. We request that you make every effort to sign up and use our
portal as we can provide information, articles and links regarding your care as well as get you
results as quickly as possible. It also allows you to correspond with us privately at your
convenience rather than playing phone tag.
If you do not read our message to you in a week it will automatically return to us as unread. If
the message is returned or if we believe we need to contact you with the results, we prefer to
text you. Our initial text will ask you if you prefer to be called or texted to receive your results.
I consent to receiving a text that my results are available:
Tina Gingrich, MD
3122 Milrany Ln. Melissa, TX 75454
(214) 295-8675
Wildflowerwomenscenter.com
Email address:___________________________________________________________________
Phone#_________________________________________________________________________
Print Name __________________________________________________________________________________
Signature _____________________________________ Date __________________________
Tina Gingrich, MD
Wildflowerwomenscenter.com
OFFICE: 214-295-8675
FAX: 866-207-2534
3122 Milrany LN. Melissa, TX 75454
Understand the requirements of HIPPA, We are not allowed to give medical or billing information to
anyone without patient consent. However, many patients allow family members such as spouses, parents or
others to call and request this information. If you wish to have your medical or billing information released
to family members, you must sign this form.
Print Name:______________________________________Date:________________________
Patient Signature:______________________________________________________________
AUTHORIZATION TO RELEASE RECORDS TO FAMILY MEMBERS
Information will be given only to individuals indicated below.
I, ____________________________________, born on _______________ hereby authorize Wildflower
Women’s Center to release my medical and/ or billing information to the following individuals.
I understand that I have the right to revoke this authorization at anytime and that I have the right to inspect
or copy the protected health information to be disclosed.
I understand that the information disclosed to any above recipient is no longer protected by federal or state
law and may be subject to redisclose by the above recipient.
I understand that I have the right to revoke this consent in writing.
Name
Name
Name
Relationship to Patient
Relationship to Patient
Relationship to Patient
Phone #
Phone #
Phone #
