COMPLETE WOMEN’S HEALTH CARE
200 Lilly Road NE Bldg B
Olympia, WA 98506
(360) 754-9409
You are scheduled for an appointment with Julie Dybbro, ARNP, PhD/Michele Harriage, ARNP/Stephine Heitkemper, ARNP on ______at ______. Please arrive 15 minutes prior to your appointment time.
Prior to your appointment, please go on-line, using Internet Explorer, to our patient portal at cwhcwa.com. At the time of your registration, you should have been provided with a user id and password. If you do not have this, please call our office and we will provide it to you. Once you have logged in to the patient portal, you need to go to “My Health Record” and enter your information. You will also need to go to “Instruction Forms” and print out “New Patient Paperwork”. Please fill this out and bring it with you to your appointment along with your insurance card.
We are very excited that you have chosen us for your healthcare needs. We want your visits at our office to be pleasant, enjoyable and as easy for you as possible. We would like to take this opportunity to introduce you to some of our policies and expectations.
As you know, medical care can be very expensive. We are contracted with most insurance companies. However, it is your responsibility to check your benefits and coverage with your insurance company prior to services being provided. If you have a co-pay, you will need to pay it at the time of service. All co-pays that are not paid at the time of service are subject to a $7.00 administrative fee. This fee will not be covered by your insurance. If you do not have insurance, payment is due at the time of service. We do accept VISA and Mastercard. Any balance that is not paid within thirty days will be subject to a finance charge of 1% (12% APR).
If you are unable to keep your appointment, please let us know at least 24 hours prior to your appointment. If you cancel late (less than 24 hours notice) or no-show your initial appointment, you will not be rescheduled. Established patients that fail to give us 24 hours notice, or no-show, will be charged a$50.00 administrative fee. This fee will not be covered by your insurance. This will need to be paid before we are able to see you again. If you no-show or cancel late two times, we will no longer be able to act as your medical provider. If you are more than ten minutes late for your appointment, we may need to have you reschedule. New patients to our office that no-show the first visit will not be rescheduled.
When you are in need of a medication refill, we ask that you contact your pharmacy and have them fax us a refill request. Please allow 72 hours notice for your refill. Our fax number is 360-438-6760.
If you have a medical emergency, please call 911 or go to the emergency room at St.PeterHospital. If you have a medical concern during office hours, please call the office at the below number and you will be transferred to one of the provider’s assistants. If you have concerns or questions regarding your treatment, and you have a follow-up appointment scheduled, we ask that you discuss these with your provider at the time of your appointment. Phone calls and emails that require more than ten minutes may be charged as an office visit. These typically will not be covered by your insurance. It is usually best to call the office and schedule an appointment.
Please feel free to call us if you have any further questions. We look forward to meeting with you.
My signature below acknowledges that I have read and understand the policies of this office.
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Patient Name (please print)
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SignatureDate
COMPLETE WOMEN’S HEALTH CARE
200 Lilly Road NE Bldg B
Olympia, WA 98506
(360) 754-9409
DATE: ______SOCIAL SECURITY #:______
PATIENT NAME: ______DATE OF BIRTH: ______
(First, Middle Initial, Last)AGE: ______
PATIENT ADDRESS:______
(Street, City, State, Zip)
______
HOME PHONE #: ______WORK PHONE #: ______
CELL PHONE #: ______EMAIL: ______
EMPLOYER: ______OCCUPATION: ______
SPOUSE/DOMESTIC PARTNER NAME: ______
EMPLOYER: ______
OCCUPATION: ______WORK PHONE: ______
NAME OF PERSON WHO REFERRED YOU TO THIS CLINIC:
PATIENT’S MEDICAL ALLERGIES:
______
IF PATIENT IS A MINOR, NAME OF PERSON FINANCIALLY RESPONSIBLE FOR PATIENT (GUARANTOR MUST SIGN PAGE 2):
______PHONE: ______
ADDRESS (If different than above) ______
DATE OF BIRTH: ______SOCIAL SECURITY #: ______
EMPLOYER: ______WORK PHONE #: ______
______
NAME OF INSURANCE SUBSCRIBER: ______
(If other than patient)
RELATIONSHIP TO PATIENT: ______SOCIAL SECURITY #: ______
DATE OF BIRTH: ______EMPLOYER: ______
OCCUPATION: ______WORK PHONE: ______
PERSON OUTSIDE OF HOME TO CONTACT IN CASE OF EMERGENCY: ______
NAME: ______ADDRESS: ______
RELATIONSHIP: ______PHONE NUMBER: ______
HEALTH INSURANCE INFORMATION
Please give us all pertinent information regarding your insurance coverage. If you have coverage by more than one carrier, supply information of both carriers. Please list all numbers on your card(s). Please check your insurance policy for a waiting period before coverage of pre-existing clauses. IF YOUR COVERAGE IS CONTINGENT ON A SECOND OPINION OR PER-ADMISSION APPROVAL, IT IS YOUR RESPONSIBILTY TO INFORM US.
PRIMARY COVERAGE: ______ID#: ______
SUBSCRIBER NAME: ______GROUP #: ______
SECONDARY COVERAGE: ______ID#: ______
SUBSCRIBER NAME: ______GROUP #: ______
DATE OF BIRTH:______
FINANCIAL RESPONSIBILITY
All professional services rendered are charged to the patient and are due at the time of services. We will bill your health insurance, however, YOU ARE responsible for all fees, regardless of insurance coverage.
ASSIGNMENT OF BENEFITS
I hereby assign all medical benefits to Complete Women’s Health Care. I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical plan to issue payment directly to Complete Women’s Health Care for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any. I understand that I am responsible for any amount not covered by insurance.
AUTHORIZATION TO RELEASE INFORMATION
I hereby authorize Complete Women’s Health Care to furnish and/or release any information necessary to insurance carriers concerning my illness and treatments, to process my insurance clam acquired in the course of my examination or treatment, to allow a photocopy of my signature to be used to process my insurance claim for the period of lifetime. This order will remain in effect until revoked by me in writing.
I have requested medical services from Complete Women’s Health Care on behalf of myself and/or my dependents, and understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of the treatment authorized. I further understand that fees are due and payable on the date that services are rendered and agree to pay all such charges incurred in full immediately upon presentation of a billing statement. A photocopy of this assignment is to be considered as valid as the original.
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SignatureDate
COMPLETE WOMEN’S HEALTH CARE
Julie A Dybbro, ARNP, PhD
Michele Harriage, ARNP
Stephine Heitkemper, ARNP
HEALTH EVALUATION
______Birthdate: ______Age: ______
DatePrint Name
____ Married_____ Partnered ____Widowed ____ Single
Name of spouse/partner: ______
Patient Phone:______Cell: ______Work: ______
Email: ______Can we email sensitive information here? ____Yes ___ No
Is there a number we can leave a detailed message with sensitive information? ___Yes ___ No, please specify: ______
By law we cannot share any medical information without your permission. Is there anyone you would like us to share your medical information with? ______
What are you here for today? ______
If you are here for an annual exam, we will bill your insurance for a preventative exam. A preventative exam is a “well person” exam. If you have other problems or concerns, or if an abnormality is found during your exam, we may bill your insurance for an additional office visit. Your insurance may charge an additional office visit co-pay.
Who is your primary care provider? ______-______
Who do you see for your annual/physical exams? ______
CURRENT HEALTH HISTORY (Check all that apply)
Blood Clots/ThrombophlebitisCancer (type)______
Fibrocystic DiseaseHeart Disease
FibroidsDiabetes
Abnormal Vaginal BleedingHigh Blood Pressure
Vaginal DischargeStroke
Musculoskeletal painImpaired Liver Function
Vaginal ItchingADD/ADHD
EndometriosisBipolar Disorder
Abnormal Pap Smear & TreatmentSchizophrenia/Psychosis
Polycystic Ovary DiseaseDepression
OsteoporosisAnxiety/Panic Disorder
OsteopeniaBorderline Personality Disorder
Hepatitis/Liver DiseaseChronic vaginal discomfort
Headaches or migraines (Menstrual Pattern? Y N)Pain with Sex
Changes in bowelsSexual Issues:
Changes in urineChanges in Hearing:
Changes in visionOther: ______
Erection problems
CURRENT MEDICATIONS AND DOSAGES (including over-the-counter):______
______
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CURRENT SUPPLEMENTS/VITAMINS/HERBS: ______
______
DRUG/FOOD ALLERGIES: ______
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LIST ALL SURGERIES AND PROCEDURES (INCLUDING BIOPSIES) INCLUDE DATES, REASONS AND RESULTS
______
Last Bone density test (DXA) Date: ______Results: __Normal ___Osteopenia ____Osteoporosis
Last Mammogram and Result: ______Last Pap Smear and Result: ______
Last Colonoscopy and Result: ______Last Cholesterol and Result: ______
Last Rectal Exam: ______Last PSA date and result (Men): ______
Last testicular Exam: ______
****PLEASE PROVIDE US WITH COPIES OF YOUR LAST MAMMOGRAM, PAP SMEAR, LABS, AND BONE SCAN, IF AVAILABLE ****
OBSTETRICAL HISTORY
# of pregnancies _____# vaginal births _____#C Sections _____# live births _____
# of miscarriages _____# of abortions _____# of ectopic pregnancies _____ Fertility problems? Y N
Have you used fertility medicine? Y N
FAMILY HISTORY
Relationship
Cancer (type) ______
Heart Disease before age 50______
Anyone have a heart attack before age 50?______
Diabetes______
Osteoporosis______
High Blood Pressure______
Maternal exposure to DES______
Colon Cancer______
TO WHAT DEGREE DO YOU EXPERIENCE THE FOLLOWING?
None / Slightly / Moderate / Severe / ExtremeLack of Sexual Desire
Inability/difficulty to Reach orgasm
MENSTRUAL PERIODS
NoneWhen was your last period? ______
Regular
Irregular
Recently changing
Bleeding between periods
What are they like? (heavy, light, how long, how often, painful, etc.) ______
______
Are you sexually active? Y N
Do you have sex with: _____ Men_____ Women _____ Both
Form of Birth Control, if needed? ______
Any problems with this form of birth control? ______
Are you and your partner monogamous? ____ Yes ___No ____Unsure
Have you ever had and/or been treated for:
- Herpes (genital)
- HPV (Human Papilloma virus)
- Chlamydia
- Gonorrhea
- Cold Sores
- Other ______
Have you had an abnormal pap smear? Y N If yes, please provide result and treatment ______
______
Do you smoke? Y N Quit (date) ______Alcohol amount per week ______
Do you use marijuana or street drugs? Y N If yes, please specify: ______
Have you currently or in the past been concerned about addictions with alcohol, prescription or non-prescription drugs? Y N specify: ______
How much do you exercise? ______Type: ______
Are you happy with your current weight? Y N If no, please specify why: ______
Do you eat a healthy diet? Y NHow much caffeine (coffee, tea, pop) you drink? _____cup/cans/week
Have you unintentionally gained or lost >10# in the past 3 months? Y N
Have you been in an abusive relationship?Y N
Have you ever been forced to have unwanted sexual activity in your life?Y N
Hormone Replacement Therapy History: (Include dates of use and results) ______
______
______
If you desire to receive Hormone Replacement Therapy, what are your goals? ______
______
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Notes and/or Questions (or anything else you would like us to know about you): ______
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COMPLETE WOMEN’S HEALTH CARE
200 Lilly RD NE, Bldg B
Olympia, WA 98506
Ph: 360-754-9409Fax: 360-438-6760
RECEIPT OF NOTICE OF PRIVACY PRACTICES
I have received a copy of the Notice of Privacy Practices, which fully describes the uses and disclosures that can be made of my individually identifiable health information for treatment, payment and health care operations. If I refuse to sign receipt of this, Complete Women’s Health Care can refuse to treat me.
PERSONAL MESSAGES REGARDING MY HEALTH AND TEST RESULTS MAY BE LEFT ON MY VOICE MAIL OR ANSWERING MACHINE.
- YESDate ______Initials ______
Phone # to leave message ______
- NO, except to return a call or appointment reminder.
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Signature of patient or patient’s representativeDate
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Printed name of patient or patient’s representativePatient’s Date of Birth
______
Relationship to the patient
I give my permission for the following individuals to receive personal health information about me. Please give name and relationship to you. This permission will be binding until revoked in writing by me.
1. ______Relationship: ______
2. ______Relationship: ______
3. ______Relationship: ______
4. ______Relationship: ______