a practice by John P. Schilling, MD

Obstetrics Gynecology Cosmetic Surgery Medical Aesthetics

We would like to sincerely thank you for choosing our practice. Our goal is to de-velop a trusting relationship with you and provide excellent care and services to keep you healthy. We even offer some extra services to keep you looking as good as you feel.

Our doctors are dedicated to keep up with the latest training, techniques and prac-tices on complex female health issues. You can feel confident they will listen to you and understand your personal needs.

Our practice is unique because we offer obstetrical and gynecological services, medi-cal aesthetic services, and cosmetic surgery.

Now that you have your appointment scheduled, we just wanted to let you know the other services we offer and would love for you to join us on social media to stay con-nected, hear the latest news, and even get special offers! Also, check out our quar-terly newsletters full of fun and informative information.

Facials - Facial ServicesChemical PeelsHome Skin Care ProductsHyper-Pigmentation RosaceaMicrodermabrasionBotox® Dysport®

Juvéderm® Radiesse® Sculptra®

Laser Stretchmark Reduction

Laser Skin Tightening/Anti-AgingLaser Hair ReductionLaser Vein TreatmentWeight-LossSmartlipo® & LiposuctionLipo-Abdominoplasty (Tummy Tuck)Facial Fat GraftingButtocks EnhancementBreast Augmentation

Please tell us what you would like more information about:

1757 Rock Quarry RoadStockbridge, GA 30281

Women’s Center (770) 474-7151Weight-Loss (770) 474-7151 Cosmetic Surgery Center (770) 506-9123Medical Aesthetics (770) 506-9123

Address:

Phone:

John P. Schilling, MD, FACOGTamika L. Sea, MDTope K. Olubuyide, MD

Website: SchillingMedicalSpa.comSchillingWomensCenter.com

Email: talktous@schillingmedicalspa.com

Social Media: facebook.com/johnschillingmd@drjohnschilling

Online Newsletter: issuu.com/schillinghealthcare

PatientData Form

a practice by John P. Schilling, MD 1757 Rock Quarry RoadStockbridge, GA 30281

T (770) 474-7151 F (770) 506-1915

SchillingWomensCenter.com

Patient ID: (FOR OFFICE USE) Today’s Date:

Patient Name:Address:

Mailing Address (if different): Home: Cell: Work: Email Address:How did you hear about us?

DOB: Social Security #:

Marital Status: Single Married Divorced Separated Widow

EMERGENCY CONTACT Name:EMERGENCY CONTACT Phone:Relationship:

Can we discuss medical issues with this person?Any exceptions?

check preferredcontact number

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(if) Student - School: Employed - Occupation:Employer: Employer PH #:Employer Address: City: ST: Zip:

PERSON FINANCIALLY RESPONSIBLE: (If patient, skip to Section C)Relationship: DOB: Social Security #:(Please complete if home address is different from patient)Home Address: City: ST: Zip: Home: Cell: Work: Email Address: (Responsible party) EMPLOYER: Employer PH #:Employer Address: City: ST: Zip:

Name of Primary Insurance: Policy #:Insurance PH #: Group #:Are you the policy holder? Yes If NO, Please fill out next part of Section C (and D if applicable)Policy Holder’s Name: Relationship to patient:Sex: M F DOB: Social Security #:(Please complete if home address is different from patient)Home Address: City: ST: Zip:EMPLOYER: Employer PH #:Employer Address: City: ST: Zip:

Sect

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Name of Secondary Insurance: Policy #:Insurance PH #: Group #:Policy Holder’s Name: Relationship to patient:Sex: M F DOB: Social Security #:(Please complete if home address is different from patient)Home Address: City: ST: Zip:EMPLOYER: Employer PH #:Employer Address: City: ST: Zip:

Authorization to release information: I hereby authorize the Schilling Healthcare (dba Schilling Women’s Center) to release any information acquired in the course of my treatment necessary to process insurance claims.

Authorization to pay benefits to Schilling Healthcare (dba Schilling Women’s Center): I hereby authorize payment to Schilling Women’s Center providers of the Surgical and/or Medical benefits, if any, otherwise payable to me for his/her services as described, realizing that I am responsible to pay non-covered services.

Signature: Date:

check preferredcontact number

John P. Schilling, MD, FACOG Tamika L. Sea, MD Tope K. Olubuyide, MD

Female HealthHistory

a practice by John P. Schilling, MD 1757 Rock Quarry RoadStockbridge, GA 30281

T (770) 474-7151 F (770) 506-1915

SchillingWomensCenter.com

Patient ID: Today’s Date:Patient Name:Address:

Mailing Address (if different): Home: Cell: Work:Your Employer:Employer Phone #:

DOB: Current Age:Religious Consideration:Marital Status: Single Married Divorced Separated WidowRace:Type of Insurance:Referring Physician:Primary Physician:REASON FOR VISIT:

Have you or any membersof your family had? SELF FAMILY High CholesterolHeart DiseaseHigh Blood PressureAsthmaTuberculosisDiabetesThyroid ProblemsLiver DiseaseIntestinal ProblemsStomach, Bowel orGall Bladder ProblemsKidney or Bladder ProblemsBreast ProblemsAIDS (HIV)Hepatitis (Type ___ )Anemia or Blood DisorderCancerInfertilityEndometriosisOsteoporosisLupusBlood TransfusionSeizuresMigrainesDepressionDomestic ViolenceAbnormal Pap SmearAbnormal MammoGenital wartsHerpesChlamydiaGonorrheaSexual ProblemsDES ExposureNO KNOWNMEDICAL PROBLEMS

check preferredcontact number

First Day of Last Menstrual Cycle:

Age at First Period:# of Days Between Periods:Length of Period:

ABNORMALITIES Excessive Bleeding Discharge Pain NONE

# of Full-Term Births# of Premature Births# of Miscarriages# of Terminations# of Living Children

# ofBirths

BORNMonth / Year

Baby’s Sex

M / F

Weightat Birth

WeeksPregnant

Hoursin

Labor

Type ofDeliveryVAG / CS

Type ofAnesthesia

Complications

YES NO

1 / lb oz

2 / lb oz

3 / lb oz

4 / lb oz

5 / lb oz

TYPE PRESENT IN LAST 5 YRS Oral Contraceptive Types

IUD Diaphragm Norplant Sponge Spermacide Condoms Other Sterilization Male Female

Date of last Pap smear?Has your Pap test ever been abnormal?

Are you sexually active?Is intercourse painful to you?

Have you had a mammogram?If so, last date of mammogram:

Do you exercise regularly(3+ hours a week)?

If so, Light Moderate Heavy

MEDICAL & FAMILY HISTORY MENSTRUAL HISTORY PRENANCY HISTORY

CONTRACEPTIVE HISTORY LIFESTYLEplease complete all info

please complete all info

HOSPITALIZATIONS List operations/serious illnesses that have required hospitalization. DO NOT LIST PREGNANCIES HERE.

IF more than 6, check this box, list others below.

MONTH/YEAR ILLNESS OR OPERATION COMPLICATIONSYES NO

CURRENT MEDICATIONS nonetYpe dosaGe

MEDICATION ALLERY/SENSITIVITY

PATIENT SIGNATURE

SUBSTANCE ABUSEPLEASE CHECK ONLY THAT YOU USE

TYPE AMT/DAY

AlcoholTobaccoCaffeineNon-PrescribedDrugs or Street Drugs

none knoWn

YES NO

YES NOYES NO

YES NO

YES NO

John P. Schilling, MD, FACOG Tamika L. Sea, MD Tope K. Olubuyide, MD

Dr. John P. Schilling, Dr. Tamika L. Sea & Dr. Tope K. Olubuyide would like to WELCOME you to Schilling Healthcare!

For your convenience we have created our patient forms in a PDF form-fill format. You may type in information and print or print form and complete by hand.

Please note, your information is strictly protected by HIPAA and cannot be misused. You may ask for a complete copy of our HIPAA policy. The personal information such as address, birth date, and social security number is required to properly identify you and your health records to your insurance company and to our practice. If you do not complete this information or falsify any portion knowingly, we cannot accept you as a patient in our practice.

We realize there can be concerns of identity-theft when your personal information is involved, therefore we will protect your information with the highest degree of privacy possible. If there are special concerns, please discuss this with our financial counselor / billing depart-ment at (770) 474-7151.

Please follow instructions below:

You need to download the latest version of Acrobat Reader (FREE) at: http://get.adobe.com/reader/

Fill out ALL information completely.

Click on “PRINT” button when done and

Mail to us at: Schilling Healthcare 1757 Rock Quarry Road Stockbridge, GA 30281

Bring to appointment.

Note: Do not email. Email is not secure and we do not want to put your personal information in jeopardy of being stolen.

Before your appointment you may want to call your insurance company and check your ben-efits for yearly deductible and co-pay information. As insurance costs are rising and more responsibility is being directed to the individual - this will prepare you for any cost the insur-ance may not cover or will be applied to your deductible.

When you come in for your visit, please bring your driver’s license and insurance card.

Please note we do not accept checks. We DO ACCEPT Cash, Debit or Credit Cards. We apologize for any inconvenience.

We look forward to meeting you!

or

a practice by John P. Schilling, MD

Obstetrics Gynecology Cosmetic Surgery Medical Aesthetics

1757 Rock Quarry RoadStockbridge, GA 30281

Women’s Center (770) 474-7151Weight-Loss (770) 474-7151 Cosmetic Surgery Center (770) 506-9123Medical Aesthetics (770) 506-9123

Address:

Phone:

John P. Schilling, MD, FACOGTamika L. Sea, MDTope K. Olubuyide, MD

Website: SchillingMedicalSpa.comSchillingWomensCenter.com

Email: talktous@schillingmedicalspa.com

Social Media: facebook.com/johnschillingmd@drjohnschilling

Online Newsletter: issuu.com/schillinghealthcare