Your First Visit

Please register at the reception desk when you arrive for your first appointment. For your first visit to our office, please come 15 minutes before your appointment to register and fill out patient information forms. We will also need information about your insurance coverage. Please bring your insurance cards with you to every appointment.Should any information change between visits, let us know so we can update your records.

Appointments

We see patients on an appointment basis and ask that you call in advance so that we may reserve an appropriate time for you. If you can not keep an appointment, please let us know as soon as possible so that we may offer that appointment to someone else. Failure to cancel an appointment in advance may result in a billing for the missed appointment.

If you have many questions or problems that may require an extended visit with your healthcare provider, please inform the appointment secretary so that she may schedule an appropriate amount of time for your visit. If you need to make an appointment for a complete or annual physical, please call us a month or so in advance so that we may better accommodate you. As a courtesy to other patients that are in the waiting room, we ask that you limit your visit to the specific problem that you are scheduled for.

We sincerely try to stay on schedule. Unfortunately, unforeseen emergencies and problems arise. We ask for your patience when these delays occur.

If you feel that your wait time is excessive, please mention it to the receptionist so that she can verify the reason for your delay. However, if your schedule does not allow for the delay, please notify the receptionist so that she may reschedule you at your convenience.

When Bringing Children

Since a physician’s office and examination rooms are not child proof, children older than eight weeks must remain in the waiting room. Newborns and babies up to eight weeks of age may accompany their mothers to the exam room. The exception, of course, is the child who is a patient.

For the safety of our high-risk obstetrical patients and post-surgery patients, we must limit their exposure to the viruses and illnesses frequently carried by children. For this reason, we ask that you refrain from bringing children to our office. We appreciate your understanding and cooperation with this request. If it is necessary to bring your children, please make arrangements to have an adult supervise them in the waiting room while you have your exam or procedure.

Pre-Registration

Last Name
First Name
Middle Name
Maiden Name
Address
City State Zip
Home Phone
Email
Date of Birth
Religion
Employer
Occupation
Work Phone	Ext
Social Security #
Race	Please Select Caucasian African-American Hispanic other
Marital Status	Please Select Single Married Widowed Divorced Legally Separated
Spouse's Information (if Applicable) or other responsible party
Last Name
First Name
Middle Name
Address (If different than above)
Address
City State Zip
Home Phone
Date of Birth
Employer
Occupation
Work Phone	Ext
Person outside your household to contact in case of emergency
Name
Relationship to patient
Home Phone
Work Phone	Ext
Do you want us to release financial and/or medical information to other family members or friends? Yes No
If yes, please state their name and relationship to you:
Name
Relationship to patient
Please indicate the type of information to be released Financial Medical Both
To all of our new patients, the physicians and staff of Ashley Women's Center extend a most cordial welcome. We strive to provide the very best health care with the highest patient consideration. To all of our established patients who are updating their records, we thank you for your patronage and pledge to you to continue the best health care and consideration that we can offer. Thank you for choosing Ashley Women's Center for your medical needs. We look forward to a satisfied and continued relationship with you.

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