ANNUAL PATIENT UPDATE
Please note that it is important to fill in all the fields before submitting. Thank you.
General Information
Patient Name :
*
First Name
Middle Name
Last Name
Date of Birth :
*
-
Month
-
Day
Year
Date
Home Address :
*
Street Address
Apartment #
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
-
Month
-
Day
Year
Date
ID#:
Group #:
Insured Person:
SS#:
Insured’s Name:
Medical History
Have you received the COVID vaccine?
*
Yes
No
If so, when was your first dose?
-
Month
-
Day
Year
Date
When was your second dose?
-
Month
-
Day
Year
Date
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
-
Month
-
Day
Year
Date
To
-
Month
-
Day
Year
Date
Last Mammogram:
-
Month
-
Day
Year
Date
Date of last pap smear:
-
Month
-
Day
Year
Date
Bone Density Test:
-
Month
-
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
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: