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utah women pregnancy center

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Forms

To help us stay on time with appointments, please have your paperwork completed and plan to arrive at least 20 minutes before your scheduled appointment time.

All new patients please fill out the Patient Information, Lab Consent form, E- prescribe Consent form and Authorization to Release Protected Health Information. Also, if you are pregnant, please fill out the Pregnancy consent and Pregnancy Questionnaire. lf you are not pregnant, please fill out the Gynecology Health History form.

If you are a returning patient, please complete the Patient information and Lab Consent form each year.

Any time that your insurance or Contact information changes, please notify the receptionist.

If you choose to fax the Completed forms to us, please use the Fax Cover Sheet and fax them to 435-628-1722.

Completed forms can be faxed to 435-628-1722.

Completing these forms and sending them prior to your appointment can reduce your wait time. You may also bring the completed forms to your appointment. Please give the forms to the receptionist when you check in.