Grandmother With Mother And Adult Daughter Relaxing On Sofa, Smiling To Camera

Patient Forms and Videos

New Patient Packet Form

We understand that filling out forms takes time, and we appreciate your efforts to complete them. It is, however, the best way for our team to understand your current health, what concerns you have, and the goals you wish to achieve by seeking urogyn specialty care. Please complete the New Patient packet and bring it with you to your first visit.

Download Form

Surgical Assist Consent Form

Download Form

Notice of Privacy Practices

Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.

Authorization for Release of Medical Information

Allows patients to authorize the disclosure of their health information to a designated individual, company, agency, or facility.

Authorization and Consent for Treatment

All patients must provide their consent for treatment, communications (calls, emails, and text messaging), and agreement of financial responsibility. Autorización y Consentimiento Para el Tratamiento

Preferred Contacts

Patients are encouraged to complete and return the Preferred Contacts Form but it is not required. Contactos Preferidos

Financial Policy

This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.