Legacy Obstetrics & Gynecology - Medical History Form

Legacy Obstetrics & Gynecology Appointment Request
Non Urgent Appointment Request Form For questions about your appointment, please contact us at (404) 288-0746. Use this form to request a non-urgent appointment only. If you have an immediate medical problem, please call 911 or proceed to the hospital. All requests will be processed within 72 hours during regular business hours, Monday - Friday, 9:00 am - 4:00 pm. If we do not contact you by phone to confirm your appointment request, please call our office at (404) 288-0746. Note: If this will be your first appointment with us, please use our Registration Forms and bring to your appointment. * Denotes Required Information Patient Information
First Name*
Middle Initial
Last Name*
Date of Birth* MM DD YYYY
Appointment Information
Preferred Day*
Preferred Time*
Provider*
Purpose of Appointment*
What insurance do you have?*
Contact for Appointment Confirmation
Contact Name*
Daytime Phone* xxx-xxx-xxxx
E-mail Address required for e-mail confirmation
Preferred method of contacting you to confirm appointment Phone E-mail Address