Date: ___/___/_____ Physician: ____________
Referring Physician:
Chart No:________ Social Security #: ______________

Name:

Address:

Home Phone: ____________________ Nature of visit: Pregnancy__ Routine__ Problem__

Employer: ____________________________________ Occupation: _____________

Employer Address: ____________________________________ Work Phone: _______________

Date of Birth: ___/___/_____ Single__ Married__ Separated__ Divorced__ Widowed__

Husband/Parent Name: ______________________ DOB: ___/___/_____ SS# __________

Employer: _______________________________________ Work Phone: ______________

Marriage Date: ___/___/_____

Emergency contact:	__________________________________ Relationship: __________
	Home Phone: _______________ Work Phone: _________________

Primary Insurance Company: ______________________________________________

Subscriber or ID number: _____________________ Group Number: ______________

Name of Policyholder: __________________________________ DOB: ___/___/_____

Policyholder
Employer/Address:

___________________________________________________________

Patient’s Relationship to Policyholder: self__ spouse__ child__ other______________

Secondary Insurance Company: ______________________________________________

Subscriber or ID number: _____________________ Group Number: ______________

Name of Policyholder: __________________________________ DOB: ___/___/_____

Patient’s Relationship to Policyholder: self__ spouse__ child__ other______________

I authorize Richmond OB-Gyn Associates to release any medical information necessary to process my insurance claim(s), and I authorize payment of benefits to Richmond OB-Gyn Associates.

I understand that I am responsible for payment of services and that if my account becomes delinquent it may be turned over to a collection agency or attorney. In this event, I agree to pay all additional collection agency fees, court costs, and attorney’s fees.

Signature: ____________________________________________ Date: ___/___/_____

Patient Name: ___________________________________________
Date: ___/___/_____
Patient's Height: ______ Weight: ______ Age: ______

Number of Children: __________ Miscarriages: ________ Abortions: _________

Age of first menstrual period: _____ Periods occur every _____ days and last about ____ days

First day of last menstrual period: ________________________________________________

Have you ever received a blood transfusion? _____

If so, when and how many? ______________________________________________________

Drug Allergies: ________________________________________________________________

Other Allergies: _______________________________________________________________

Current medications (list): _______________________________________________________

____________________________________________________________________________

Comments: ___________________________________________________________________

_____________________________________________________________________________

Notice of Deemed Consent to Blood Testing

A law was enacted in Virginia in 1993 which authorizes health care providers to test their patients for HIV and Hepatitis B and Hepatitis C antibodies when the health care provider is exposed to the body fluids of a patient in a manner which may transmit human immunodeficiency virus (HIV), the virus that causes Acquired Immunodeficiency Syndrome (AIDS) and related disorders, hepatitis B, or C viruses. Because of this law, in the event of such an exposure, you will be deemed to have consented to the release of the test results to the health care provider who may have been exposed.

In the event of an employee exposure, you will be informed before any of your blood is tested for HIV, hepatitis B, or hepatitis C antibodies. The testing will be explained, and you will be given the opportunity to ask questions you may have. You will be provided with the test results and appropriate counseling. These results, if positive, are required to be reported to the Virginia Department of Health.

I have read and understand the above "Notice of Deemed Consent to Blood testing."

Signature: ____________________________________________ Date: ___/___/_____