Women's New Patient Intake Form

Intake Form

For your first visit, please fill out the form online and submit it (recommendation) OR download the following three forms and bring the completed form with you.

FEMME CLINIQUE PATIENT INTAKE FORM Download

FEMME CLINIQUE FEMALE PATIENT CONSENT HORMONE THERAPIES Download

FEMME CLINIQUE PATIENT PAYMENT AGREEMENT Download

Intake Form Online

You do not need to download and fill out the above document for online submission.

First Name

Last Name

Date of Birth

Email Address

Phone

Gender

Address

Address2

City

State

Zip

Occupation

Hours per week

Employer

How did you hear about this clinic?

Emergency Contact

Relationship

Phone

Insurance Information

Name of the Insurance

Primary Subscriver

Subscriver ID Number

Group Number

Health History Questionnaire

What are your most important health problems? Please list them in order of importance.

Family History

Hospitalizations / Surgery / Accidents

What hospitalizations or surgeries have you had?

Year

Were you ever knocked unconscious?

Yes

No

Have you ever had a lapse of memory?

Yes

No

Toxic Profession Past or Present

Artist, graphic designer, dental assistant, gas station worker, painter, industry cleaner, etc.

Age

Major Psychological Trauma

Age

Serious Infection / Disease

Pneumonia, mono, TB, cancer, heart attack, stroke, hepatitis, etc.

Age

Long periods on prescriptions or street drugs

Age

Long visits or lived in a foreign country like India, Mexico, etc.

Age

Treated for Parasites and/or infection?

Yes

No

Allergy

Are you hypersensitive or allergic to:

Current Medications

Please list any prescription medications, over the counter medications, vitamins, or any other supplements you are currently taking:

FEMME CLINIQUE

INFORMED FEMALE PATIENT CONSENT HORMONE THERAPIES

Please read and sign the following informed consent agreement:

Your visit includes a private examination with a licensed physician. Your doctor will talk to you about your medical condition and perform any physical examples or lab tests medically indicated and agreed upon by you for the chief concern that brought you to the clinic.

I UNDERSTAND THAT BLOOD TESTS AND MEDICAL HISTORY WILL BE USED TO ESTABLISH MY BASELINE HORMONE STATUS. I AGREE TO FOLLOW ALL RESONABLE REQUESTS FOR ONGOING LAB TESTING TO ENABLE FEMME CLINIQUE PHYSICIANS TO TREAT ME EFFECTIVELY. IN ADDITION, I WILL REPORT ANY POTENTIAL ADVERSE REACTIONS OR CHANGES IN MY MEDICATIONS OR DOSING TO FEMME CLINIQUE SO THEY CAN HELP ME OPTIMIZE MY TREATMENT BENEFITS AND PREVENT ANY SIDE-EFFECTS AND AS WITH ANY THERAPY I UNDERSTAND THERE ARE POTENTIAL SIDE EFFECTS ATHOUGH THEY TEND TO BE MINIMAL. POTENTIAL SIDE EFFECTS INCLUDE MOOD CHANGES, ACNE, HAIR LOSS/GROWTH, BREAST TENDERNESS, AND ABNORMAL MENSES. I UNDERSTAD THAT MY TREATMENT IS DESIGNED TO MINIMIZE ANY OF THESE SIDE EFFECTS AND INCREASE BENEFITS OF THE THERAPY. I AGREE TO COMPLY WITH THE RECOMMENDED DOSES TO HELP PREVENT ANY COMPLICATIONS.

I UNDERSTAND THAT I WILL BE IN CHARGE OF ADMINISTERING MY HORMONES AND SUPPLEMENTS AS PART OF MY TREATMENT AND I UNDERSTAND FEMME CLINIQUE CANNOT BE HELD RESPONSIBLE FOR MY MISUSE OF ANY MEDICATIONS. I UNDERSTAND THAT FEMME CLINIQUE IS MANAGING ONLY MY CARE IN RESPECT TO HORMONE THERAPY AND AGREE TO HAVE A PRIMARY CARE PROVIDER FOR OTHER HEALTH ISSUES UNLESS OTHERWISE EXPLICITLY AGREED UPON BY BOTH PARTIES. I UNDERSTAND THAT FEMME CLINIQUE WILL BE AN ADDITION TO MY MEDICAL CARE BUT NOT A REPLACEMENT FOR MY PRIMARY MEDICAL PROVIDER. I AGREE TO RECEIVE YEARLY MAMMOGRAMS AND PAP SMEARS AND REPORT ANY ABNORMAL RESULTS TO MY PHYSICIAN AT FEMME CLINIQUE.

I UNDERSTAND THAT I HAVE THE RIGHT TO CHOOSE ANY PHARMACY FOR FILLING MY PRESCTION FROM FEMME CLINIQUE.

If you have read the above statements and understand them, please sign and date:

Date

Your signiture

FEMME CLINIQUE PATIENT PAYMENT AGREEMENT

**PLEASE READ CAREFULLY AND SIGN AFTER READING**

We at Femme Clinique are here to help you to take care of your health in the best way that we know how. We realize you came in about health and not finances. The following is to assist you in understanding Femme Clinique financial policies:

Payment Requirements

Appointments must be paid for at time of service unless otherwise agreed. We accept VISA, MasterCard, Discover, American Express, Cash, and Check. You will be charged a $25 fee for a returned check.

Appointment

We require 24 hours in advance of notice if you need to reschedule or cancel our appointment. You will be charged a $50 No Show fee for a missed appointment.

Medical Records

We keep a record of your health care. Please allow up to 10 business days for us to process a medical record request. A processing fee will be charged for this service if requested by a third medical records requesting company. We will not disclose your records to others unless you direct us to do so or unless it is required by the law.

Insurance and Fee

Femme Clinique is contracted with Premera and Regence currently. Cash discount is available for patients who don’t have Premera and Regence as their medical insurance. We are entitled to bill the patient for charges that their insurance does not cover. Please understand that the patient is responsible financially for their visit to Femme Clinique.

I have read and understand the above statements.

Thanks for submitting!

営業時間

月曜〜金曜

8:00〜20:00

土曜

9:00〜19:00

日曜

9:00〜21:00