ANY CHANGES ONLY FORM
Stephen M. Zweibach, M.D. Mariel Rotundo-Patino, D.O.
Natasha J. Champion, M.D. Marian Sampson, M.D.
We send all labs outside for processing and therefore you may receive a billing, of which you will be responsible for,
from an outside Lab (Counsyl, Quest or Lab Corp). We are required to send the labs with the diagnosis from your visit and cannot change the diagnosis so the bill will be paid
PATIENT DEMOGRAPHICS – Complete all lines
Patient Name: ______Date: ______
Address: ______Apt/Lot #______City______State____ Zip______
Home Phone: ______Cell Phone:______Work Phone: ______
Date of Birth: ______Age: ______SS# ______Marital Status: ( )M ( )S ( )D ( )W
Patient’s Employer: ______Phone #: ______
Primary Care Physician: ______Phone #: ______
Patient’s Pharmacy: ______Location: ______Phone #: ______
Patient’s Email: ______Preferred Daytime Contact: ______
Web Portal Acknowledgement: You will be given web user information as this is how our office will correspond with you for NON-URGENT results; you can also view medical records and/or send us a message for any concerns you have.
Emergency Contact: ______Phone #: ______
With my signature, I authorize WOMEN’S HEALTH & WELLNESS the right to release my medical information for the purpose or treatment, payment and healthcare operations. I acknowledge I have been given a copy of Notice of Privacy Practices and office Policy and Procedure, and financial policies. I agree that a copy of this signed agreement shall be as valid as the original. For Annual Visits – if you choose or your Doctor chooses to discuss any problems during your Annual, an extra Office Visit is charged and that charge may be subject to a deductible and/or copayment by your Health Plan which you will be responsible to pay. We send all labs outside for processing and therefore you may receive a billing of which you will be responsible for, from an outside Lab (Quest, Counsyl or Lab Corp).
If you are unable to keep an appointment, we need a 24hours’ notice. If you miss your appointment and did not speak with someone and do not have their name, our office reserves the right to charge a Missed Appointment feedepending on appointment type. Cancellation fees for surgical procedure(s) require a 10 day notification and insufficient notification will assess a fee on your account.
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Signature of Patient or Legal GuardianDate
______Print Name (and Relationship – if other than Patient) Date
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815 South Parsons Avenue, Brandon, FL 33511 (813) 571-2777 Phone
13148 Vail Ridge Drive, Riverview, FL 33579 (813) 571-2888 Fax