VAGINAL INFECTIONS HISTORY OF: D YEAST Q TRICHOMONAS D CHLAMYDIA D HERPES D GONORRHEA D BACTERIAL VAGINOSIS

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1 NAME: DOB: AGE: TODAY'S DATE: REFERRED BY: FAMILY PHYSICIAN: REASON FOR VISIT: MENSTRUAL HISTORY MENSTRUATED FIRST TIME. AT THE AGE OF: WHAT IS THE FIRST DAY OF YOUR LAST MENSTRUAL PERIOD?. PERIOD INTERVAL (Number of days between 1 s ' day to 1 st day): DURATION OF BLEEDING: PAIN OR CRAMPING WITH PERIODS? D NONE D MILD D MODERATE D SEVERE MEDICATIONS FOR PAIN? D YES D NO IF SO, WHAT? HOW HEAVY ARE YOUR PERIODS? D LIGHT D MODERATE D HEAVY Q VERY HEAVY DO YOU HAVE CLOTS WITH YOUR PERIODS? D YES D NO HOW OFTEN DO YOU CHANGE YOUR PAD/TAMPON (in hours)? ANY BLEEDING BETWEEN YOUR PERIODS? DYES DNO VAGINAL INFECTIONS HISTORY OF: D YEAST Q TRICHOMONAS D CHLAMYDIA D HERPES D GONORRHEA D BACTERIAL VAGINOSIS DO YOU HAVE ANY UNUSUAL VAGINAL DISCHARGE? D YES LI NO PAP TEST DATE OF LAST TEST: NORMAL? DYES D NO HISTORY OF ABNORMAL PAPS? D YES Q NO PRIOR TREATMENT FOR YOUR PAP SMEARS? DYES D NO SCREENING TESTS DATE OF LAST MAMMOGRAM TEST: NORMAL? D YES D NO EXPLAIN: DATE OF LAST DEXA/BONE DENSITY: NORMAL? D YES D NO HISTORY OF ABNORMAL MAMMOGRAM? DYES D NO DATE OF LAST COLON CANCER SCREENING:. PERFORM MONTHLY SELF BREAST EXAMS? D YES D NO CONTRACEPTIVE HISTORY CURRENT METHOD: D PILLS (What brand?. NORMAL? D YES D NO ) D DEPO-PROVERA D PATCH D NUVARING D DIAPHRAGM D SPERMACIDES D CONDOMS Q VASECTOMY / TUBAL D OTHER: D NONE ARE YOU SATISFIED WITH YOUR CURRENT METHOD? DYES D NO PAST METHODS: OBSTETRICAL HISTORY NUMBER OF: PREGNANCIES. PREMATURE MISCARRIAGES. FULL TERM ABORTIONS LIVING CHILDREN MENOPAUSE SYMPTOMS (Check all that apply) D HOT FLASHES D VAGINAL DRYNESS D MEMORY OR CONCENTRATION PROBLEMS D NIGHT SWEATS D IRREGULAR PERIODS D INSOMNIA OR DIFFICULTY SLEEPING SEXUAL HISTORY ARE YOU CURRENTLY SEXUALLY ACTIVE? D YES Q NO HAVE YOU HAD MORE THAN ONE SEXUAL PARTNER? DYES D NO D SATISFACTORY HOW MANY? _ D WISH TO DISCUSS AGE AT ONSET OF SEX? ' ANY BLEEDING WITH INTERCOURSE? YES D NO ANY PAIN WITH INTERCOURSE? D YES D NO

2 SOCIAL HISTORY SMOKING: DYES Q NO # of years. IF SO, Cig / day. CAFFEINE: Cups / day. ALCOHOL: Drinks / week _J DO YOU USE ANY OTHER STREET DRUGS? DYES D NO DO YOU HABITUALLY USE LAXATIVES? DYES D NO MARITAL STATUS: D SINGLE D MARRIED DO YOU USE MARIJUANA? Q YES D NO IF SO, WHAT?. HOW LONG? D SEPARATED D DIVORCED Q WIDOWED PAST MEDICAL HISTORY (Please check if you have any of the following conditions.) D MEASLES D HEART DISEASE D DIABETES D HEADACHES / MIGRAINES D HIATAL HERNIA / REFLUX D ARTHRITIS D EPILEPSY/NEUROLOGIC D ASTHMA D KIDNEY DISEASE D PEPTIC ULCER DISEASE DCOPD D HIGH CHOLESTEROL D THYROID DISORDER D BREAST DISEASE D LIVER DISEASE D ANEMIA / BLOOD DISORDER DCANCER D BOWEL DISEASE D BLOOD TRANSFUSION D DVT/BLOOD CLOTS D SKIN DISEASE D HIGH BLOOD PRESSURE D OSTEOPOROSIS D EYE DISEASE D VENEREAL DISEASE D ANXIETY /DEPRESSION D MENTAL DISORDER D OTHER MEDICATIONS (List all medications including vitamins, supplements, and over-the-counter medications): MEDICATION ALLERGIES: SURGERIES (Please check if you have had any of the following surgeries and list dates): D BREAST n CESAREAN SECTION D OVARY D D& C DTUBES J KIDNEY STONES_ D UTERUS D APPENDIX D VAGINAL REPAIR D GALLBLADDER D BLADDER / KIDNEY D BOWEL D CERVIX (Leep, cone, or laser)_ D HEMORRHOID_ D HERNIA D LUNG/CHEST D HEART D JOINTS D BACK D TONSILS D OTHER FAMILY HISTORY (Please list who in your family, if any, have been diagnosed with any of the following): M = Mother, F=Father, S=Sister, B=Brother, MGM=Mother's mother, MGF=Mother's father, PGM=Father's mother, PGF=Father's father DOWN'S SYNDROME DES EXPOSURE. MENTAL DISORDERS, MENTAL RETARDATION BIRTH DEFECTS THYROID DISORDER CYSTIC FIBROSIS_ BLOOD DISORDERS HIGH CHOLESTEROL_ BLOOD CLOTS HUNTINGTON'S CHOREA STROKE KIDNEY DISEASE_ HEART DISEASE ~_ DIABETES OVARIAN CANCER_ BREAST CANCER HIGH BLOOD PRESSURE OTHER CANCER COLON CANCER UTERINE CANCER OSTEOPOROSIS MELANOMA DO YOU OFTEN HAVE ANY OF THE FOLLOWING? DYES QNO (Circle all that apply) GENERAL: chills, fever, night sweats, hot flashes, fatigue, weight change, appetite change EAR, NOSE, THROAT: nose bleeds, sores in mouth, hoarseness, sore throat, earache, sinus headache RESPIRATORY: cough, shortness of breath, wheezing, asthma GENITOURINARY: pelvic pain, pain with intercourse, vaginal discharge, blood in urine, bladder infections, loss of urine, frequency, urgency SKIN: unusual growth of hair, moles, rashes, swollen lymph nodes, breast lump or pain, nipple discharge NEURO: seizures, frequent headaches, dizziness CARDIOVASCULAR: chest pains, heart attack, heart disease, hypertension, stroke, irregular heart rate, elevated cholesterol BONES, JOINTS: leg cramps, joint or muscle pain, back pain, osteoporosis GASTRO-INTESTINAL: difficulty swallowing, blood in stool, change in bowel habits, constipation, diarrhea, nausea, vomiting, heartburn, reflux PSYCH: depression, anxiety, mood swings, sleep disturbances Aerify that this information is true and accurate to the best of my knowledge. Signature of patient or legal guardian Signature of RN/CMA Signature of physician

3 Laurianne Scott, D.O., LLC 135 North Ewing Street, Suite 205 Lancaster, OH Phone: FINANCIAL POLICY AND AGREEMENT Thank you for choosing us as your women's health care provider. We are committed to providing you with the best possible medical care. Please understand payment of your bill is considered a part of your treatment. The following information is provided to avoid any misunderstanding or disagreement concerning payment for services, tests, and supplies provided by our office. 1. Our office participates with a variety of insurance plans. It is your responsibility to: a. Bring your current insurance card to every visit and notify us of changes in coverage. b. Be prepared to pay your co-pay at each visit. Payment may be made by cash, check, MasterCard or Visa. If I don't receive a bill, I understand that it is my responsibility to pay the amount due. c. We will submit a claim to your insurance company for you. Balances not paid, per our contact by your primary insurance company may be billed to your secondary payer. A statement will be sent to you. Ultimately, you are responsible for payment of services and for any out amount above what was collected at time of service. d. Be prepared to pay any outstanding balance plus your co-pay, coinsurance, and/or deductible at check in for each visit. Payment can be made by cash, check, MasterCard or Visa. e. I understand that my insurance carrier can choose to assign benefits to Laurianne Scott, D.O., LLC or my insurance carrier may make payment directly to me. f. I understand and certify that I am financially responsible for all health care service charges that are paid to me directly by my insurance carrier, as well as for any applicable co-payment, coinsurance, deductible or charges for non-covered services provided to me or any of my dependents. 2. If you do not have insurance coverage or if you are insured by a company with which we are not contracted, payment in full is expected at time of service unless payment arrangements are made and kept. 3. If you have questions about your insurance, we are happy to help you. Specific coverage issues, however, should be directed to your insurance company member services department (number should be listed on your card). 4. This office charges for all services that are significant and separately identifiable. Patients that are seen for physical exams and require other treatments for illnesses or problems may be charged separately for each service even when both are provided on the same day. 5. This office can only code and file a claim for a patient's visit with a diagnosis that was encountered and documented in the medical record. To request a diagnosis change solely for the purpose of securing reimbursement from the insurance carrier is inappropriate and could be considered a fraudulent act. 6. All balances billed are due within 25 days of the statement date. Unpaid balances greater than 25 days are subject to a $25.00 late fee and subject to our collection process. Accounts sent to our collection agency are subject to a collection charge of S50.00 for balances up to SI50.00 and for balances of $ and higher the fee is 35% of the outstanding balance. 7. There will be a $25.00 fee charged for all appointments that were not kept and/or cancelled prior to the appointment time. 8. Co-pays not paid at the time of service may result in processing fee of $ There is a $25.00 fee on all returned checks.

4 10. For medical record requests made by the patient or the patient's personal representative, the charge is tallied accordingly: Pages 1-10, S2.73 per page; Pages 11-50, $0.57 per page; Pages 51&up, $0.23 per page. Actual cost of any related postage to be incurred will also be added to the fee to copy any or all medical records. The fee for medical records will be waived if the records are to be used for continuation of care and sent directly to the provider's office. 11. For medical record requests made other than the patient or patient's personal representative, there is a $16.78 fee for all records searches, then the charge is tallied accordingly: Pages 1-10, $1.11 per page; Pages 11-50, $0.57 per page; Pages 51 & up, $0.23 per page. Actual cost of any related postage to be incurred will also be added to the fee to copy any or all medical records. The fee for medical records will be waived if the records are to be used for continuation of care and sent directly to the provider's office. 12. There is a sliding fee for FMLA and/or Disability forms. This is a form fee to be paid prior to the form being completed and is charged as follows: $20.00 for 7 business days turn-around; $40.00 for 3 business days turn-around; and $60.00 for next business day turn-around. 13. Yearly well woman exams may or may not be covered under your health insurance policy; however, they may be required by your physician. Some forms will not be filled out and/or signed if physicals are not up to date. 14. If you cancel, miss or no show for three (3) appointments you may be dismissed from the practice. Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. By signing below, I certify that I will pay Laurianne Scott, D.O., LLC any co-payments, coinsurance, deductibles or noncovered services. I will immediately pay Laurianne Scott, D.O., LLC any payments that I receive from my insurance company for services provided to me or my dependents. I will also be responsible for any amounts not paid by insurance because I have not provided the appropriate insurance information for billing. I understand and agree that if my account is delinquent, Laurianne Scott, D.O., LLC may deny me or my dependent, as named above further supplies and services or may require that I pay for supplies and services at the time of the visit. I certify that the information I have provided is a true and complete statement according to my best knowledge and belief, and that a full explanation of services and charges has been given to me. I understand that if I give false information, withhold information or fail to report changes promptly, I will be breaking the law and can be prosecuted and/or have services discontinued. PRINT PATIENT' S NAME DATE SIGNATURE OF PATIENT OR GUARDIAN WITNESS

5 - Laurianne Scott, D.O. 135 North Ewing Street, Suite 205 Lancaster, Ohio Telephone (740) CONSENT FOR RELEASE OF INFORMATION NAME: DATE: WHERE ARE WE ALLOWED TO ATTEMPT TO CONTACT YOU WITH TEST RESULTS? (please circle) HOME: YES NO IF YES, what is your home telephone number? WORK: YES NO IF YES, what is your work telephone number? CELL PHONE: YES NO IF YES, what is your cell phone number? PLEASE LIST FAMILY MEMBERS TO WHOM WE ARE PERMITTED TO GIVE TEST RESULTS: NAME RELATIONSHIP MANY TIMES WHEN CALLING, WE REACH AN ANSWERING MACHINE OR VOIC , ARE WE ALLOWED TO LEAVE A DETAILED MESSAGE WITH TEST RESULTS? (please circle) YES NO Patient/Guardian Signature: Date: NOTE: TEST RESULTS OF A SENSITIVE NATURE WILL ONLY BE GIVEN DIRECTLY TO THE PATIENT. OTHER TEST RESULTS MAY REQUIRE A FOLLOW-UP VISIT WITH THE PHYSICIAN TO DISCUSS.

6 From the office of Laurianne Scott, D.O. NOTIFICATION TO ALL PATIENTS The rigid regulations of the insurance industry require us to have you sign the following release. PLEASE READ THE FOLLOWING CAREFULLY I agree to pay for any and all medical services I receive from Dr. Laurianne Scott that my insurance company refuses to pay, for whatever reason. This office will file a claim on my behalf, however, if my insurance company denies payment for any reason (i.e. non-covered services, does not pay for preventive medical visits, failure to secure a referral from my primary care physician, etc.) I will pay for the services upon written/verbal notice of their refusal to pay. Failure to pay within 45 days of filing is for the purpose of this agreement constitutes a refusal to pay. I further agree and understand that this office can only code and file a claim for my visit(s) with a diagnosis that we encountered and documented in my medical record. Thus to ask this office to change a diagnosis solely for the purpose of securing reimbursement from an insurance carrier is inappropriate and may result in a fraudulent act. Insurance Release: I hereby assign all medical benefits to which I am entitled to Laurianne Scott, D.O. in the event they file on my behalf. I understand that I am financially responsible for all charges whether or not paid by said insurance. In the event my account becomes delinquent and is therefore in default of payment, I accept responsibility for the principal amount owing as well as reasonable costs associated with the collection of this debt. This includes but is not limited to collection service fees, attorney's fees, and all court costs and additional legal fees associated with the recovery of this debt. I hereby authorize said assignee to release all information necessary to secure the payment of said benefits. A copy of this assignment shall be considered as effective and valid as the original. Consent to Treatment; I do hereby consent to such treatment, by the authorized personnel of Laurianne Scott, D.O. as may be dictated by prudent medical practice, of my illness, injury or condition. This consent is intended as a waiver for such treatment. Responsible Party Signature:. Date:

7 HIPPA Receipt Confirmation: I have received a copy of Laurianne Scott, D.O. 's Notice of Patient Information Practices. Responsible Party Signature: Date: Release of Pharmacy and Medication Information I give Laurianne Scott, D.O. permission to access my medication information from my insurance company and any pharmacies. Pharmacy Name and Location: Responsible Party Signature: Date:_