The Women’s Wellness Center Terrence W. Harris, MD, FACOG • Gail Pezzullo-Burgs, MD, FACOG

Patricia Chen, MD, FACOG • Lindsay Leider, CNM, APRN Patient Information Sheet Date:

Name: Date of Birth: First Last

What is your primary language?: Marital Status: single married divorced widowed Street Address: City: State: Zip: Home Phone: ( ) - E-Mail:Cell Phone: ( ) - Employer: Occupation:Work Phone: ( ) - Extension:Emergency Contact: Phone: ( ) - Which Pharmacy do you use?: Phone: ( ) - How did you find us: Referral from a Doctor Name:

Referral from a Patient Name: Yellow Pages (print edition) Internet Search Engine Which one?: Other:

Insurance Information Primary Ins. Co: Secondary: ID #: ID #: Group #: Group #: Subscriber: Subscriber: (check one) Self Spouse Dependent (check one) Self Spouse Dependent SS# or Date of Birth: SS# or Date of Birth: Ins. Co. Phone: ( ) - Ins. Co. Phone: ( ) - Primary Care Provider: Primary Care Provider:

Statement of Financial Responsibility I certify that the above information is correct and further authorize the release of any medical information to my insurance carriers for any claim. I request payment of authorized benefits to the physician furnishing the service, or authorize the physician to submit a claim for me. I, the undersigned, realize that all medical and surgical charges incurred by me or my dependents for services rendered by Drs. Harris, Chen and Pezzullo-Burgs are my financial responsibility. I also agree that should my account be referred to any agency or attorney for collection, I will be responsible for all attorney fees, collection fees, and court costs. I understand that payment is expected when services are rendered, unless prior arrangements have been made.

Signature: Date:

Medicare Lifetime Authorization I certify that the information given by me in applying for payment under Title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to Medicare for payment.

Signature: Date:

The Women’s Wellness Center Terrence W. Harris, MD, FACOG • Gail Pezzullo-Burgs, MD, FACOG

Patricia Chen, MD, FACOG • Lindsay Leider, CNM, APRN 2500 N. Military Trail, Suite 111 • Boca Raton, FL 33431

Phone: (561) 826-3800 • Fax: (561) 826-3744

HIPAA Compliance Patient Consent Form Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. A copy of it is located at the check-in desk and one may be provided to you at your request. The notice contains a patient’s rights section describing your rights under the law. Your signature ascertains that you have reviewed our notice before signing this consent. The terms of the notice may change. If so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, you understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.• The practice reserves the right to change the privacy policy as allowed by law.• The patient has the right to restrict the use of the information, but the practice does not have to agree to those

restrictions.• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.• The practice may condition receipt of treatment upon execution of this consent.

May we discuss your medical results/condition with anyone besides yourself? YES NO *This includes results related to sexually transmitted diseases, pregnancy, or psychiatric disorders and will only begiven to this person by special permission.If YES, please name the authorized person(s) and specify the relation to you: ___________________________________________________________________________________________________________________________

I hereby authorize the staff at Women’s Wellness Center and/or Drs. Harris, Chen or Pezzullo-Burgs to notify me of any laboratory or diagnostic results by calling the following telephone numbers:

Call me at the following telephone number first: ( ) - _This is a: Home Phone Cellular Phone Work Phone Okay to leave voicemail?: YES NO *only check “YES” if you or any authorized persons will be the only ones checking this voicemail

If I cannot be reached at the above number, call: ( ) - _This is a: Home Phone Cellular Phone Work Phone Okay to leave voicemail?: YES NO *only check “YES” if you or any authorized persons will be the only ones checking this voicemail

Notify me by e-mail that I have results available (results will NOT be provided by e-mail). This option will only be used if I cannot be reached by telephone.

My e-mail address:

Reviewed by (PRINT NAME PLEASE):

Patient Signature: Date:

The Women’s Wellness Center Terrence W. Harris, MD, FACOG • Gail Pezzullo-Burgs, MD, FACOG

Patricia Chen, MD, FACOG • Lindsay Leider, CNM, APRN

2500 N. Military Trail, Suite 111 • Boca Raton, FL 33431 Phone: (561) 826-3800 • Fax: (561) 826-3744

Due to the current medical malpractice crisis, your physician does not carry medical malpractice insurance.

Under Florida law, physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice. Your doctor has decided not to carry medical malpractice insurance. This is permitted under Florida law subject to certain conditions. Florida law imposes penalties against non-insured physicians who fail to satisfy adverse judgements arising from claims of medical malpractice.

This notice is provided pursuant to Florida law.

F.S. 458-320

Acknowledged:

Print Name

Date

Signature

The Women’s Wellness Center Terrence W. Harris, MD, FACOG • Gail Pezzullo-Burgs, MD, FACOG

Patricia Chen, MD, FACOG • Lindsay Leider, CNM, APRN

2500 N. Military Trail, Suite 111 • Boca Raton, FL 33431 Phone: (561) 826-3800 • Fax: (561) 826-3744

FORMS POLICY

This is an acknowledgment of our policy regarding any forms that a patient requires this office to complete. There is a $25.00 fee to complete said forms. The forms would include, but are not limited to, FMLA (Family & Medical Leave Act), Disability, Hospital Indemnity Plans, Return to Work and other forms or packets that require more than a handwritten note on a prescription pad. This policy has been established to accommodate the additional time needed by our staff to review, assess necessity, prepare documentation & complete the paperwork. Please provide this office with the necessary contact information of where the forms need to be sent. Payment is required before completion of the forms. PRINT NAME SIGNATURE/DATE

The Women’s Wellness Center Terrence W. Harris, MD, FACOG • Gail Pezzullo-Burgs, MD, FACOG

Patricia Chen, MD, FACOG • Lindsay Leider, CNM, APRN 2500 N. Military Trail, Suite 111 • Boca Raton, FL 33431

Phone: (561) 826-3800 • Fax: (561) 826-3744

NO-SHOW/LATE ARRIVAL POLICY

There will be a $25.00 charge for each No-Show or Late Arrival without 24 hour advance notice.

This policy has been established to help us serve you better by ensuring we have space in our schedule to accommodate same-day sick visits.

It is necessary for us to make appointments in order to see our patients as efficiently as possible. No-shows & late arrivals cause problems that go beyond a financial impact on our practice. It prevents another patient from having a much-needed appointment when there is actually time available. No-shows & late arrivals delay the delivery of health care to other patients; some who are quite ill.

A “No-Show” is defined as missing a scheduled appointment with no notice. A “Late Arrival” is defined as arriving more than 10 minutes past a scheduled appointment.

We understand that situations such as medical emergencies occasionally arise. These situations will be considered on a case by case basis.

PRINT NAME SIGNATURE/DATE

2500 N. Military Trail, Suite 111 • Boca Raton, FL 33431 Phone: (561) 826-3800 • Fax: (561) 826-3744

The Women’s Wellness Center Terrence W. Harris, MD, FACOG • Gail Pezzullo-Burgs, MD, FACOG

Patricia Chen, MD, FACOG • Lindsay Leider, CNM, APRN

CANCER FAMILY HISTORY QUESTIONNAIRE PATIENT NAME: DATE OF BIRTH: PHYSICIAN SEEING: TODAY’S DATE:

Please only circle YES if your history exactly matches the questions on this form

CANCER FAMILY HISTORY SELF

Please list your FAMILY MEMBER w/ CANCER AGE AT

DIAGNOSIS MOTHER’S SIDE

FATHER’S SIDE

Y N Breast cancer diagnosed at age 49 or less

Y N TWO relatives on the same side of the family with breast cancer, one diagnosed at age 50 or younger

Y N Ovarian cancer at any age

Y N THREE relatives on the same side of the family diagnosed with breast cancer at any age

Y N Ashkenazi Jewish ancestry with a breast, ovarian, prostate or pancreatic cancer in the family

Y N Male breast or metastatic prostate cancer at any age

Y N Pancreatic cancer at any age

Y N Endometrial/uterine or colon cancer diagnosed before age 50

Y N THREE or more of the following cancers on the same side of the family at any age: colon, endometrial, ovarian, gastric/stomach,

pancreatic, brain, small bowel, renal/pelvic

Have you ever been tested for BRCA or Lynch Syndrome?

Patient is appropriate for testing: YES / NO Patient accepted genetic testing: YES / NO Patient Signature: Provider Signature:

This is a screening tool for cancers that run in families. Please INCLUDE these family members: Mother/Father/Sister/Brother/Children

Aunt/Uncle/Grandparents/Niece/Nephew/1st Cousin