Initial Intake FormAustin Women’s Care Prior to your initial appointment, fill out all sections and then hit submit initial intake button. Date of scheduled initial appointment * MM DD YYYY Name of Provider * Anna Robinson, MD Your Name * Date of Birth * MM DD YYYY Brief reason for initial consult * Best Phone Number to Reach You * (###) ### #### Call Back Preference * Okay to leave a detailed voicemail/text message Just leave a callback number Emergency Contact * Emergency Contact's Phone Number * (###) ### #### Referred By (person's name or where you found us) Medication List * Please list all medication, doses, and prescribing instructions (e.g., Aspirin, 81 mg, once a day) Medical Issues * Please list any medical issues or previous surgeries (e.g., diabetes, high blood pressure) Release of Information * If you would like us to collaborate with other providers/loved ones, please go to our Release of Information page and fill out the form; this gives us permission to contact them. No Release of Information needed at this time Release of Information needed. I will go fill out the form after I submit my initial intake. Anything else you'd like us to know that may help us with your care? Please check all of the following: * I have reviewed and understand the Office Policies and Notice of Privacy Practices (first link under 'Patient Forms'). I have read and understand policies regarding fees and financial arrangements. I understand that I must keep an active credit card/HSA/FSA card on file. I am responsible for updating this card when appropriate. I understand that my credit card/HSA/FSA card will be charged after appointments. I understand that appointment cancellations require 24 hours’ notice via phone during normal business hours. Monday cancellations must occur before noon the previous Friday. I also understand that the office does not accept cancellation requests via e-mail or weekend voicemails. If I do not follow the cancellation policies, I understand that I am responsible for the provider’s full out-of-pocket fee. I understand that Austin Women's Care does not prescribe controlled substances such as benzodiazepines (Xanax, Klonopin) or stimulants (Adderall, Ritalin) at the first few visits. Thank you for taking the time to fill out your initial intake online. We appreciate you!
