PATIENT INFORMATION When registering please provide proof of insurance and Picture ID Payment is expected at time of service.

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KENTUCKY FERTILITY, GYNECOLOGY AND OBSTETRICS PRIMARY HEALTH CARE 170 North Eagle Creek DR Suite 101 Lexington KY 40509 Phone 859-277-5736 Fax 859-276-2236 PATIENT INFORMATION When registering please provide proof of insurance and Picture ID Payment is expected at time of service. NAME ADDRESS CITY STATE ZIP SEX M / F HOME PHONE CELL PHONE DATE OF BIRTH AGE MARITAL STATUS SOCIAL SECURITY # - - EMPLOYED Y / N STUDENT Y / N EMPLOYER OCCUPATION ADDRESS CITY STATE ZIP PHONE SPOUSE / GAURDIAN RELATIONSHIP PHONE EMPLOYER PHONE PRIMARY CARE PHYSICIAN PHONE ADDRESS HOW DID YOU HEAR ABOUT US? PREFFERED PHARMACY PHONE EMERGENCY CONTACT PHONE RELATIONSHIP

PRIMARY INSURANCE INFORMATION COMPANY POLICY HOLDER RELATIONSHIP TO PATIENT DATE OF BIRTH PHONE SS# ADDRESS IF DIFFERENT THAN PATIENT EMPLOYER PHONE SECONDARY INSURANCE INFORMATION COMPANY POLICY HOLDER RELATIONSHIP TO PATIENT DATE OF BIRTH PHONE SS# ADDRESS IF DIFFERENT THAN PATIENT EMPLOYER PHONE RESPONSIBLE PARTY IF OTHER THAN PATIENT NAME DATE OF BITH ADDRESS CITY STATE ZIP PHONE SS# EMPLOYER PHONE I CERTIFY THAT THE INFORMATION I HAVE PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE. I ALSO UNDERSTAND THAT I AM FINANCIALY RESPONSIBLE FOR ALL CAHRGES WHETHER OR NOT COVERED BY INSURANCE. SIGNATURE DATE

Kentucky Fertility, Gynecology and Obstetrics,PLLC George M. Veloudis, JR, D.O. Amy L. Claxon PA-C Name Date Age Birthdate Married How long? Religion Referred by: Widowed Single Seperated Divorce Who do you live with? Last year of school Completed Occupation Race Ethnicity Smoker Y or N How much Alcohol consumption Y or N How much Drug use Y or N Type: Number of Pregnancies and type of delivery Number of miscarriages Number of elective abortions Number of Living Children/Ages Last Mammogram Date Location Last PAP date Abnormal history Y or N Treatment received? Menses regular or irregular Post menopausal? Last Menstrual Cycle Are you Pregnant? Allergies Y or N Type and reaction List all hospitalizations and surgeries below. (Do not include normal pregnancies) Month/year Physician Location/Hospital Type of Surgery

List all Medications you are currently taking, dosing and reason for taking: FAMILY HISTORY: Mother Age Health Problems: Father Age Health Problems: Check if you, brothers, sisters, parents, grandparents, aunts or uncles have had the following. Please specify if yourself or which relative it is concerning. Diabetes- Heart Disease- Epilepsy- High Blood Pressure- Cancer- Multiple Births- Kidney Disease- Mental Illness- Birth Defects- TB- Arthritis-

Frequent Headaches-

Kentucky Obstetrics and Gynecology, PLLC 170 North Eagle Creek Drive, Suite 101 Lexington, KY 40509 Phone(859) 277-5736 Fax(859)276-2236 Consent to Treatment I/we voluntarily authorize the rendering of such care, including diagnostic procedures and medical treatment, by Dr. George M. Veloudis, Amy L. Claxon PA-C, and/or staff at Kentucky Obstetrics and Gynecology, PLLC, as may in their professional judgment be deemed necessary or beneficial, and may include testing for HIV and drug screening. I/we acknowledge that no guarantees have been made as to the effect of such examination or treatment on my condition or the condition of the person for whom I am duly authorized to sign. I/we understand that I/we have the right to make decisions concerning my health care or the health care of the person for whom I am duly authorized to make such decisions, including the right to refuse medical and surgical procedures. Release of Information I authorize the release of information from my medical records or the record of the person for whom I am duly authorized to do so; for the continuum of treatment. Including the following entities, any health, sickness and accident insurance carrier, workman s compensation or agency (social, welfare, governmental) which is legally responsible or which Kentucky Obstetrics and Gynecology, PLLC has good cause to believe is legally responsible for all or any part of the Kentucky Obstetrics and Gynecology, PLLC charges and /or professional fees. Release of Medical Records I also authorize the release of my medical records from other physicians, hospitals or health care facilities as it may be needed for my continuum of care or the continuum of care for whom I am duly authorized to sign with Kentucky Obstetrics and Gynecology, PLLC. Signature of Patient or duly authorized agent Date Signature of Witness Date *The above consent may be revoked at any time, except to the extent that action has already been taken, by the patient/duly authorized agent and will expire automatically one year from the date above.

KENTUCKY FERTILITY, GYNECOLOGY AND OBSTETRICS, PRIMARY HEALTH CARE GEORGE M. VELOUDIS JR. D.O. AMY CLAXON PA-C Notice of Privacy Practices for Protected Health Information (HIPAA) Acknowledgment Form I have received the notice of privacy practices and have been provided the opportunity to review it. Patient Name Birth date (please print) Signature Date

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