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Phone: 559-321-2930 / Fax: 559-321-2940

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UroGynecology Specialty Center
7060 N. Recreation Ave
Suite 104
Fresno, CA 93720

 

Patient

Registration

Form

Patient

Family

History

Patient

Medical

History

Review of

Systems

Assignment

of Benefits

It is our pleasure to welcome you as a new patient to UroGynecology Specialty Center, Female Pelvic Medicine & Urogynecology specialty center. You should have received from us an envelope in the mail containing our new patient packet. You may fill out these forms to the best of your knowledge prior to your arrival. If you did not receive anything in the mail from us we will give you a new patient packet upon your arrival, but ask that you arrive 30 minutes before your scheduled appointment time to fill out the paperwork. Our office is fully electronic utilizing an electronic health record, so it is important that you fill out your patient history and review of systems with as much detail possible. Upon completion of your paperwork, our staff will enter this vital health information into your electronic record. Please bring your insurance card and driver’s license which will be scanned into our system. We will also take a picture of you to place in your electronic record when you check-in.

Due to the nature of our practice, it is imperative that we receive your medical records for your appointment. The following is a listing of documentation that is crucial for us to have:

  1. Previous lab work mainly urinalysis or urine cultures you have had in the past.

  2. If you have had previous pelvic surgery, your operative report will need to be reviewed by Dr. Steinberg. Often, we cannot decide on a treatment plan for you without this information.

  3. Recent radiology reports such as CT scans and pelvic ultrasounds.

  4. Any documentation from other doctors you have seen for your problem.

  5. Current medication listing with correct spelling and dosage information.

 

We will request a urine sample from you during all office visits. To start your visit, you will be seated in one of our offices to discuss your complaints and to briefly discuss the types of treatment options available. After this brief discussion, we will move you to an examination room for your physical examination.