The forms below may be downloaded and filled out electronically (or printed and filled out by hand) prior to coming to your appointment.
First time patients OR patients returning after one year:
Please access the “All Patients” form links below. Review the Patient Rights and the HIPAA Notice pages - these may be printed out and kept as a reference.
Please complete the following forms prior to your appointment:
- Demographics Form/ HIPPA Privacy Form – general information (name, address, and insurance)
- Health History Form – health history, current medications, allergies, and any current symptoms.
Additional form for prenatal patients only:
Genetic Questionnaire – helps you and your provider determine what, if any, tests are necessary to rule out genetic abnormalities in your baby.
Additional forms for urogynecology patients:
Voiding Diary – helps Dr. Mitchell-Springer or Dr. Ostrom determine your level of incontinence or other urinary issues.
Please save all of the other forms from the “All Patients” folder to your computer and fill in the gray areas electronically. To fill in an area, simply click on the appropriate gray area and begin typing. (The non-gray areas of these forms are protected and cannot be changed.) Once filled out, please print your forms and bring them with you to your appointment.
If you would prefer not to save them to your computer, then you can print out the forms and fill them out by hand and bring them with you to your appointment.
Before your appointment
Please remember to:
- Bring your insurance card(s)
- Bring your photo ID (e.g. drivers license) to your appointment(s).
- Please contact your insurance company
- Find out the following: your deductible, your office visit co-pay, and your insurance preferred lab. If you go to a non-preferred lab, your insurance may not cover as much or any of the cost and the cost will become your responsibility.
Urogynecology (prolapse or incontinence)
- Urogynecology Questionnaire
- Urogynecology Voiding Diary
- Urogynecology Letter
- Urogynecology Questionnaire – a health history questionnaire that is specific to urogynecology (pelvic organ prolapse or urinary incontinence.
Prenatal genetic questionnaire
Release of Medical Records from AWH