Steven Stern M.D., Online Registration Form

Steven E. Stern, M.D.
20207 Chasewood Park Drive • Suite 201 • Houston, Texas 77070
281.893.3831 • Fax 281.320.2447

Email Insurance Questions to: rportales@sternobgyn.com

We thank you for your time and effort in completely filling out this registration form in it's entirety. Our main objective is to minimize your waiting time as we enter your information into our computer, generate a chart and verify insurance benefits. We look forward to the opportunity of seeing you at your scheduled appointment. If you are unable to keep this appointment, please notify our office as soon as possible.

Note:
RED fields are required! Please try to be as thorough as possible!

General Statistics

Patient's First Name:	Patient's Middle Initial:	Patient's Last Name:
Patient's Home Phone No:	Patient's Social Security No:	Patient's Driver's License Number and State Code:
Patient's Address:	Patient's City, State:	Patient's Zip:
Patient's Employer:	Employer's Address:	Employer's City, State, Zip:
Patient's Work Phone:	Spouse's Name:	Spouse's Employer:
Spouse's Employer Address:	Spouse's Work Phone:	Spouse's Soc. Sec. Number:
Emergency Contact:	Emergency Contact Phone Number:	Name of Relative Not Living with Patient:
Phone Number of Relative Not Living with Patient:	Pharmacy Name:	Pharmacy Phone Number:
Referring Physician or Person:	Patient's Birth Date:	Email Address:
Date and Time of Patient's First Appointment:	Marital Status:

Primary Insurance Information

Primary Health Insurance Co.	Primary Insurance Co. Phone:	Primary Insurance Co. Address:
Primary Insurance Co. I.D. Number:	Primary Insurance Co. Group or Plan Number:	Primary Insurance Co. Subscriber (or enter 'self'):
Primary Insurance Subscriber's Relationship To Patient:	Primary Insurance Co. Subscriber's Employer:	Primary Insurance Co. Subscriber's Address:
Primary Insurance Co. Subscriber's D.O.B.

Secondary Insurance Information

Secondary Health Insurance Co. (or enter 'n/a'):	Secondary Insurance Co. Phone:	Secondary Insurance Co. Address:
Secondary Insurance Co. I.D. Number:	Secondary Insurance Co. Group or Plan Number:	Secondary Insurance Subscriber:
Subscriber's Relationship to Patient:	Secondary Insurance Co. Effective Date:	Secondary Subscriber's D.O.B.

'Responsible Party' Information (ONLY NEEDED IF DIFFERENT FROM ABOVE)

Responsible Party's First Name (or enter 'self'):	Responsible Party's Middle Initial:	Responsible Party's Last Name (or enter 'self'):
Responsible Party's Birth Date:	Responsible Party's Relationship to Patient:	Responsible Party's License Number and State Code:
Responsible Party's Home Phone:	Responsible Party's Employer:	Responsible Party's Work Phone:
Resp. Party Employer's Address:	Resp. Party Employer's City, State:	Resp. Party Employer's Zip Code:

Medical Information
Please be as thorough as possible, in order to speed your first visit

List all known drug allergies, or enter 'none':

Please list the main reason(s) for your
visit, and any other information you
want us to know here:

Birth Control	Check if yes
Do you take birth control pills?
Do you use the I.U.D?
Do you use condoms, foam, jelly, or suppositories?
Have you had a Tubal Ligation?
Husband had a Vasectomy?
NO contraceptives used?

Gynecological / Obstetrical History	Your Answers
Had a Previous Hysterectomy?
Were the ovaries removed?
Any serious complications with any pregnancy?
Number of previous pregnancies (or enter '0')
Number of vaginal deliveries (or enter '0')
Number of C. Section deliveries (or enter '0')
Number of miscarriages (or enter '0')
Oldest Child's Birthday

Patient History	Check if yes
Are you presently a smoker?
Ever had a blood or plasma transfusion?
Ever had diabetes?
Ever had high blood pressure?
Ever had heart disease?
Ever had mitral valve prolapse?
Ever had blood clots in legs?
Ever had hepatitis?
Ever had sexually trans. disease?
Date of last mammogram or enter n/a

Any Family History of...	Check if Yes	Relationship to Patient
Breast Cancer
Pelvic Cancer
Colon Cancer
Other Cancer
Diabetes
High blood pressure
Stroke
Heart Attack

Please list the medications you take regularly, including prescription, over the counter, or any natural/herbal medications
Please list any surgery (if any) you've previously had, or enter 'none'

Assignment of Insurance Benefits & Authorization for Release of Information
I hearby authorize my insurance benefits to be paid directly to the Physician and I am financially responsible for non-covered services. I also authorize the Physician to release any information required to process the claim.

The information above is accurate, and I agree with the above disclosure statement

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Press		to CLEAR ALL fields in your form.