For GYN appointment Patient Information Form, click here
Please Confirm Visit Type: (required)Surgical AbortionMedical Abortion Pill
Email: (required)
INSURANCE PAYMENT AUTHORIZATION AND RELEASE: I hereby authorize my insurance benefits to be paid directly to Choices Women’s Medical Center, and acknowledge that I am financially responsible for any unpaid balance. I also authorize Choices Women’s Medical Center to release any information required by my insurance company. I know it is a crime to fill out this form with facts I know to be false or to leave out facts I know are important.
PERMISSION TO TREAT: I hereby give Choices Women’s Medical Center permission to evaluate and treat the above named patient.
(BY ENTERING YOUR NAME HERE, YOU ARE COMPLETING A DIGITAL SIGNATURE)(required) Signature Date: (required)
I would like to receive Choices Monthly email Newsletter: YesNo
May we contact you via text/email/ and phone? YesNo
