Woodinville Women’s Clinic
Zora Pesio and staff welcome you. We will strive to provide you with the best possible healthcare. To help us meet
your healthcare needs, please fill out this form completely in ink. If you have any questions, please ask.
If you are here for a YEARLY EXAM it must be billed as a ROUTINE EXAM. The insurance companies require
we bill the intent of the office visit. Please understand medical insurance is your coverage, not ours, we bill as a
service to our patients. We cannot guarantee payment by your insurance company. It is your responsibility to first
check with your insurance company and your particular plan to see if your visit is covered.
We reserve the right to charge for appointments cancelled or broken without a 24-hour notice.
This section is about you:
Name:_____________________________________ M F Age:______ Birthdate:____/____/_______
Home Address:___________________________________ City:______________ State:_____ Zip:_______
Social security #:____-____-______ Home Ph. (____)______________ Cell/Pager(____)_________________
Employer:_______________________ Work Address:____________________________ Suite #:_________
City:___________________ State:_______ Zip:_______ Work Phone: (____)______________ Ext.:_____
Part Time:____ Full Time:____ Marital Status: Single___ Married___ Widowed___ Divorced___
If 18 Years or older, has an advanced directive been executed? Y / N If yes, do we have a copy?____________
This section is about your emergency contacts:
Name:________________________ Relation:________ Home Ph.:(___)__________Work Ph:(___)__________
This section is about insurance coverage for the patient:
Employer:____________________________________ SSN/ Subscriber ID#:____________________________
Subscriber DOB___/___/_____ Subscriber Ph.:(____)________________ Work Ph.:(____)________________
Subscriber Address:______________________________ City:______________ State____ Zip:_____________
Relationship to patient:_________________________________________________________________________
Authorization for treatment and financial agreement:
The above information is true to the best of my knowledge. I understand I am responsible for charges associated
with medical services, and agree to pay all bills within 30 days from the receipt of statement. I authorize
Woodinville Women’s Clinic to release any information to process insurance claims. I also authorize my insurance
to be paid directly to the clinic.
I hereby agree to give my credit card number to you when you call, to take care of ANY balances beyond 30 days of
my first billing cycle. This is including no-shows, and cancellation without sufficient notice.
How did you find out about our office?___________________________________________________________