Intake Form

Client Intake Form

  • DD slash MM slash YYYY
  • Spouse Information:
  • DD slash MM slash YYYY
  • I certify that I have read and understand the above information to the best of my knowledge. The above questions have been answered accurately.

    I understand and I agree that regardless of my insurance status, I am ultimately responsible for the valance of my account for any professional services rendered. I authorize payment of medical benefits to Southside OBGYN when assignment has been taken. I have read and agree to the office financial policy and agree to all terms and conditions and revisions of those terms and conditions.

    I authorize Southside to use or disclose any information for treatment , payment and health care operations I authorize that the physicians and ore employees of Southside OBGYN can contact me via all electronic formats( such as telephone, email, fax etc.) or leave me a message if they are unable to contact me directly.

    I have read or received a copy of the notice of privacy.