1. Patient Registration  |  2. Privacy Agreement Form  |  3. Credit Policy Form  |   4. OB/GYN History Form

Personal Information

Today's Date*

First Name*

Last Name*

Birth Date*

Social Security*

Address*

City*

State*

Zip*

Cell Phone*

Home Phone

Work Phone

Contact detail

Email Address*

Would you be interested in our patient portal?
(Please note: you will receive an email to the address listed above inviting you to join our patient portal.)
YesNo

What is your preferred appointment confirmation method?
Cell Phone - CallCell Phone - TextHome PhoneWork PhoneEmail

If you entered your email address, may we advise you via email of your normal lab results?
Yes No
(Please note that no medical information will be emailed. All abnormal results require follow-up via a telephone call.)

May we send an electronic reminder when your pap smear is due?
Yes No

Contact detail

Patient School / Employer*

Emergency Contact*

Emergency Phone*

Preferred Pharmacy*

Pharmacy Telephone*

If insured is not the employee:

Insured Member

Insured Date of Birth

Insured Employer

Insurance Company

If the insured does not live in your household please complete the following:

Address

City

State

Zip

Insured Phone

Employer

How did you hear about our office?

I hereby assign my provider at Arboretum Obstetrics & Gynecology all payments for health care services rendered to me. I understand that I am personally responsible for any financial amounts not covered by my insurance plan. Arboretum Obstetrics & Gynecology will make reasonable efforts to notify me in advance about services that may not be covered by my insurance.

Patient*

Date*

Convenient

Locations

Arboretum Office

3125 Springbank Ln.

Suite B

Charlotte, NC 28226

(704) 341-1103

Matthews Office

1450 Matthews Township Pkwy

Suite 310

Matthews, NC 28105

(704) 841-7225

Or email us at info@arboretumobgyn.com or call our office at 704-341-1103 and ask for access to the patient portal to electronically communicate with us!
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Due Date
Calendar

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News and
Events

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MedicalRecords
Policy

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Lab
Assistance

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Hospital
Pre-Registration

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Insurance
and Billing