ANNUAL PATIENT UPDATE
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General Information
Patient Name :
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First Name
Middle Name
Last Name
Date of Birth :
*
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Month
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Day
Year
Date
Home Address :
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Street Address
Street Address Line 2
City
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State
Zip Code
Cell Phone#:
*
Social Security #:
In the event of an emergency, whom should we contact:
First Name
Last Name
Phone # :
Email address :
*
example@example.com
I am aware that periodically, I may receive e-mails from Jenkins Ob/Gyn and Reproductive Medicine.
Check One:
Employed
Student
Marital Status:
Single
Married
Current Insurance Information
Insurance Company:
Insured's DOB:
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Month
-
Day
Year
Date
ID#:
Group #:
Insured Person:
SS#:
Insured’s Name:
Medical History
Any pregnancies, deliveries, miscarriages or abortions since your last visit?
Pregnancies
Deliveries
Miscarriages
Abortions
Number of Living Children
List all currently used medications -
*
Current Contraception:
Medication Allergies:
Surgery since last visit:
Last Menstrual Period -
From
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Month
-
Day
Year
Date
To
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Month
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Day
Year
Date
Last Mammogram:
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Month
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Day
Year
Date
Date of last pap smear:
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Month
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Day
Year
Date
Bone Density Test:
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Month
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Day
Year
Date
Major Medical Problems or Hospitalizations since last visit:
Pharmacy Name:
*
Telephone #:
*
Assignment of Insurance Benefits
*
I authorize payment of medical benefits to T.L. Jenkins, M.D., P.A.
Authorization To Release Information
*
I authorize T.L. Jenkins, M.D., P.A. to release any medical information as may be necessary for the complication of my insurance claim to any insurance carrier, health or hospital plan.
Acceptance of Financial Responsibility
*
I accept financial responsibility for any services not covered by my insurance.
Financial Interest Disclosure
*
In compliance with the requirements by law, you are being advised that the providers of T.L. Jenkins, M.D., P.A. have a direct financial and ownership interest in the following entities: GALA Cytology Lab and Memorial Hermann Surgery Center – Kingsland.
Signature of Patient, Parent or Guardian:
*
Date
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Month
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Date
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