Legacy Obstetrics & Gynecology - Patient registration Form

For your convenience and to expedite your appointment with us, please complete all of the forms that we have provided below. If you are transferring to us from another physician, please obtain your last office visit record and your last pap smear report and bring to your visit.

Click the form name below and simply complete all of the information then click PRINT FORM.

Please sign and bring all of the forms with you for your appointment.

Patient Registration Form (1 page)

Medical History Form (3 pages)

Notice of Privacy Policy - HIPPA

Written HIPPA Acknowledgement Form (1 page)
Sign after downloading and reading the Notice of Privacy Policy

Laboratory Wavier (1 page)

Insurance Wavier (1 page)

Record Release Request (1 page)