New Patient Visit

Please complete the following checklist prior to your visit. Be sure to bring all items with you to our office the day of your appointment.

• Patient Registration Form: Complete all sections so we can properly bill your insurance.
  Fill out this form online.
  
  
• Medical History Questionnaire: Please fill out all three pages of the form as completely and accurately as possible. You may wonder whether some questions apply to you, but please answer them nonetheless.
  
  
• Urogynecology History Questionnaire: Please fill out all three pages of this form, following the same instructions as for the Medical History Questionnaire.
  
  
• Voiding Diary Form: Please follow the directions on this sheet. Record results on the back of the sheet. You can use a standard 1 cup measuring device and label your volumes in ounces or milliliters. Urine should be discarded after each void. Please try to keep this diary for a complete 24 hour period. It is very important!
  
  
• Come to the office with a full bladder: We will perform a simple non-invasive urinating study at the time of your first visit. If you are uncomfortable on arrival and need to empty your bladder quickly, please advise the receptionist.
  
  
• Referral Form: If your insurance carrier requires a referral for specialty services, please be sure to present it at the time of your first visit. If no referral is presented at the time of this visit, it is your responsibility for payment of all services rendered that day.
  
  
• Medical Records: Please bring your previous records, or have your referring physician send us a copy of all your previous records pertaining to your visit with our office. Especially helpful are reports of previous gynecologic surgery.
  
  
• Co-Pay: Our office will require your co-pay on the day of your visit. We accept personal checks or cash; we do not accept credit cards.