Women's Health Intake Form - NovoClinic Cayman Islands

Patient Details

Please fill out all applicable fields.

First Name

Middle Name

Last Name

Is this application being made on behalf of a minor?

Birthday (dd/mm/yyyy)

Gender

Email

Phone (Work)

Phone (Home)

Phone (Cell)

Referred By

Preferred Pharmacy

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Parent/Guardian Details

Only applicable for minors

Guardian First Name

Guardian Middle Name

Guardian Last Name

Guardian Date of Birth (dd/mm/yyyy)

Emergency Contact

Please provide the contact details for your Emergency Contact

Emergency First Name

Emergency Last Name

Relationship to the patient

Emergency Phone Number

Emergency Email

Insurance Information

Please procide us with your insurance details

Insurance Provider

Certificate Number

Group Number

Medications

Please list all the medications you currently take for any reason (including non-prescription drugs):

Are you currently taking any medication?

Yes

No

Please list the medications you are taking

Drug name	Drug Dose	How Often?	Pain meds Only-Helps?

Allergies

Do you have any allergies?

Yes

No

Please list all allergies you have

Reason for Visit

Please provide us with as much detail as to the reason for your visit.

What side of the body to the symptoms relate to?

Previous Imaging?

GP / Pediatrician's Details

Have you seen another physician previously for the same issue?

Have you undergone previous surgery for the same issue?

Acknowledgement

- Please note that Co-pays are collected at the time of visit.

- I authorize the release of any medical records or other information necessary to process this claim. I understand that all medical records will be stored on a secure, encrypted server for 7 years. I understand that my data is collected, stored and shared as needed and is handled in compliance with the data protection law.

- I understand that all treatment fees will be billed directly to my insurance company provider. Please note that we charge the SHIC customary health insurance charges.

- I authorize NovoClinic to verify my health insurance benefits. I will be responsible for all co-pays/co-insurance and deductibles that may apply.

- I understand that I will be responsible for all rejected amounts billed to my insurance provider for services rendered by the medical practitioners of NovoClinic.

- I understand that any amounts outstanding for more than 90 days will be send for debt collection through the appropriate channels.

- I grant permission for licensed medical practitioners at NovoClinic to perform such examinations and medical treatments as may be professionally deemed necessary or advisable for appropriate evaluation and treatment of my condition. I understand that I will be given all available pertinent information prior to treatment being rendered. I will be given the opportunity to ask questions and to have them answered to my satisfaction.

- I understand that I may decline treatment at any time.

By checking this box you sign and agree to the above acknowledgement.

I have read and agree to the Terms and Conditions and Privacy Policy

Women’s Health Intake Form