Dr. Jukes OBGYN

PATIENT REGISTRATION AND MEDICAL HISTORY
Prior to your visit or upon arrival at our office, you will be asked to fill out several forms depending on the reason for your visit and if you are a new patient or existing patient. The following information packets and forms are listed below: New Patient Packet, Existing Patient Packet, Authorization for Release of Medical Information, Informed Consent for Mammograms and Blood Tests and the Medicare ABN Form. If you should have any questions about these forms please feel free to call the office.

Please feel free to download and print these forms in advance, completely fill them out, and bring them with you to our facility. By doing this, you will greatly reduce your waiting time. Click on a form link below to download the pdf file.

You will need Acrobat Reader to open and print it out. If you don't have Acrobat Reader, you can download it FREE here:

	New Patient Information Packet
	Existing Patient Packet
	Authorization for Release of Medical Information
	Informed Consent for Mammogr ams and Lab Tests

For Medicare Patients:
All Medicare patients coming in for an annual need to download, fill out, and bring the following form with them for their appointment.

Medicare ABN Form

The purpose of these forms is to provide us with your most current medical history and insurance information, and also to be able to answer questions you may have for us. It is important that we have as much information about your medical history as possible to allow the physician to accurately make a diagnosis and provide appropriate medical treatment.

Please bring your insurance card with you at the time of service. It is the responsibility of the patient to contact your insurance company and determine any costs that may be associated with your visit and laboratory/diagnostic tests.

All co-pays are expected at the time of service.