Patient Info

When you make an appointment with Women’s Health Services, you can expect to be treated with dignity and care in a positive, friendly environment. If you have a question or concern before, during or after your visit, please let any of our staff know and we will address the matter immediately. If you are new to our clinic, welcome. If you are already a patient, welcome back.

Forms:

No one likes to wait longer than necessary. So it’s our goal make each appointment as easy on you as possible. To speed up registration and check-in, we encourage new patients to fill out these forms before – and bring them with you on – your first visit. If at any time you have questions about these forms, programs, our providers, or our quality of care, please do not hesitate to contact us.  We want to provide you with life-long healthcare that is enjoyable and comfortable. 

• Notice of Privacy Practices
  This form indicates that we made available our Notice of Privacy Practices.  This explains your rights to health information privacy.  It is required for all patients to print their name, sign their name and to date the release. 
• Registration and Consent
  This form is signed by all new and yearly patients.  This provides us with current information on your address, phone number, emergency contact and insurance.  This also give us consent to see you for your healthcare needs.
• Sliding Fee Scale/In-House Discount
  We have a sliding fee scale available for those that qualify. To enroll for this discount, you must bring with you:
  • the completed Sliding Fee Scale/IHD form
  • Proof of income from the last 30 days, including child support, alimony, and/or unemployment
  • any child care expense paid
• Limited Authorization & Release of Information
  This form allows a friend or family member to pick up your birth control and/or to discuss your medical information.  If you would like to give Limited Authorization or Release of Information, please sign and list all people who can have access to your chart or who can pick up birth control.  Your authorization is good for one year and then must be renewed yearly.  This form can be signed by you at any time and your authorization can be revoked at any time.