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Patient Forms


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Patient Forms


Welcome! WERE YOU LOOKING TO REGISTER FOR OUR FREE RECORDS REVIEW (NO RECORDS ARE ACCEPTED WITHOUT REGISTRATION)? IF SO, CLICK HERE TO Skip Directly to New Records Review (PLEASE DO NOT REGISTER IF YOU HAVE AN IN-OFFICE APPT): Registration

Otherwise...proceed to our Patient Forms:

The free Adobe Acrobat Reader is required to access and print our forms. If you do not have it, get it for free here. NOTE ABOUT THEse FORMS: THESE ARE PDF FILES WHICH WILL AUTOMATICALLY LAUNCH AND DOWNLOAD FOR YOU. THE PAGE WILL NOT CHANGE; THE FILE WILL GO TO YOUR DOWNLOAD AREA ON YOUR COMPUTER, PHONE OR TABLET. IF YOU EXPERIENCE ANY DIFFICULTY WHATSOEVER, WE WILL BE DELIGHTED TO HELP YOU; PLEASE REACH OUT TO HEATHER@CENTERFORENDO.COM.

FOR NEW, IN-OFFICE PATIENTS WHO HAVE BOOKED AN APPOINTMENT:

****Please print and bring or send these forms in advance of your already-scheduled appointment. PLEASE NOTE: this packet is NOT for phone review patients; please see below for that link. Please - DO NOT fill out this packet if you are not a new patient with a *first-time appointment in our Atlanta offices* that has already been booked and confirmed with our staff. Free review patients, please proceed and refer to the packet below. Thank you. Please note we do not accept walk-ins and appointments are not made online. Please call 770-913-0001 if you would like to visit us in our Perimeter Center offices. Please be sure to review our In-office Appointment Cancellation Policy. We look forward to seeing you!

FOR NEW, FREE REVIEW PATIENTS:

****The New Prospective Patient Packet is required, along with the rest of the information listed in your instructional packet you received when you registered with us. Once registered, please click here to download and print this required file. PLEASE NOTE: REVIEW PACKAGES CAN ONLY BE ACCEPTED FROM REGISTERED CASES. Thank you for understanding. This packet is NOT FOR ESTABLISHED CEC PATIENTS or those who have already BOOKED AN IN-PERSON APPOINTMENT in our Atlanta offices. Please do not complete this packet if you have booked an appointment with us or have not registered; this packet should only be completed by those undergoing our free records evaluation and phone consult process. Thank you.

FOR ALL PATIENTS:

****Please review our In-office Appointment Cancellation Policy.

****A Records Release FROM your Physicians TO the CEC: Use this form

****A Records Release FROM the CEC TO other providers following your surgery with us: Use this form

****Prohibited Presurgical Medication List (always consult your surgeon for specific contraindications and permissions)

****Patient Evaluation Form: We ask that all our patients complete our evaluation following their surgery. Your responses are intended to enable us to better serve our patients.  Thank you for taking the time to share your experiences.

****Post-Surgical Follow-up Questionnaire: The Center for Endometriosis Care has long maintained one of the largest, ongoing studies evaluating the long-term results of excision of endometriosis. Your input allows us to accurately calculate our pain relief success, recurrence rates, and fertility rates over a long period of time. Without you, our accuracy decreases and our intervals of follow-up are shortened. We need your help to keep our outcomes up to date. Please help us maintain our excision study by taking a moment to fill in these details. Please complete and email/mail this form back to us. Thank you in advance!

****Our HIPAA Policy (The Health Insurance Portability & Accountability Act of 1996 is United States legislation that provides data privacy and security provisions for safeguarding your medical information)

****Our Social Media Interaction Policy (Our policy regarding our online interaction with our patients. Note that this policy pertains to our patient's interaction with our Center's staff - not to our patient's interaction with others on social media)

For website privacy, advertising and disclaimer policies, please refer to the links at the bottom of the page. Questions? Contact us anytime! WE APPRECIATE YOUR TRUST AND CONSIDERATION.

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REGISTRATION


REGISTRATION


PLEASE READ BEFORE PROCEEDING TO YOUR REGISTRATION INPUT:

The following registration form is for new records review and evaluation cases only. Please do not register if you are an existing CEC patient (current or any year prior) or have (or plan to schedule) an in-office appointment.

If you are an existing CEC patient (from any year) in need of assistance, again, please do not register.
Please call us at 770-913-0001 and we'll be delighted to help you.

If you were looking to book an in-office appointment (fees apply), please note appointments are not made online. Call us at 770-913-0001 and our staff will be delighted to book you and review the costs/insurance aspects with you. Again, please do not complete this registration form if you are not undergoing the free records evaluation and phone consult process. Thank you.

We strongly encourage our visitors to read our FAQs as well when considering the CEC for their care.

If you are unsure whether or not you've registered previously, or need to update your information on file with us, please email us to confirm we have your most current data. We do not keep registrations beyond one year prior for those who do not undergo review. Thank you.

Every registration is responded to by email with an information packet and necessary requirements for the free records review, usually within 24-48 hours except in select cases where otherwise noted. If you do not receive your packet, please check your spam file. Please take care to input your email address correctly, double-checking that you have given us accurate information. If you receive an email from one of our surgeons but not your packet of instructions, that means the mail went to your blocked/spam file. Please check and notify us accordingly.

Again - please remember: this form is NOT for those wishing to have an in-office appointment or existing patients. Do not use this form if you are coming to our offices. Please call 770-913-0001 to schedule your appointment and review costs, insurance, etc. Thank you.

Please understand that regrettably, we cannot process case reviews on an 'urgent' basis. Once discussed with Dr. Sinervo or Dr. Kongoasa, which takes 1-3 weeks from the time records are received, please allow approximately another 2 weeks for Jean to contact you to review scheduling, finances, hospital details, etc. We are currently booking surgeries 10 weeks out.

Please follow below with your registration details to get started. Please remember to fill out ALL AREAS OF REQUESTED INFORMATION (*=required), particularly full address details. You may enter 'n/a' where appropriate. Again, please remember this form is not for patients who have undergone treatment with us previously (from any year). Please do not register if you have been a CEC patient before; please contact us at 770-913-0001 and we will be delighted to help you with any concerns.

 

Date of Birth *
Date of Birth
Phone Number *
Phone Number