Click on Calendar, type the year "YYYY" and pick the month & date.
855 346 8610
23535 Kingsland Boulevard, Katy, Texas 77494 | Directions
Obgyn Katy TX - Personal & Quality Care for Women in All Phases of Life
Personal & Quality
Care for Women in
All Phases of Life
T L Jenkins MD

Annual Patient Update

Please note that it is important to fill in all the fields before submitting. Thank you.

General Information

*Patient Last Name :
Middle Name : *First Name :
Home Address :
Cell Phone#: ()--
Social Security #:
Email address :
I am aware that periodically, I may receive e-mails from Jenkins Ob/Gyn and Reproductive Medicine.
Check One: Employed Student Other: Marital Status: Single Married Other:

Current Insurance Information

Insurance Company: ID#: Group #:
Insured Person: SS#:
Insured’s Name: Insured's DOB:

Medical History

Any pregnancies, deliveries, miscarriages or abortions since your last visit?
Pregnancies Deliveries Miscarriages Abortions Number of Living Children

List all currently used medications -
Medication Name Dosage Medication Name Dosage

Current Contraception:
Medication Allergies:
Surgery since last visit:
Last Menstrual Period - From:
Last Mammogram:
Date of last pap smear:
Bone Density Test:
Major Medical Problems or Hospitalizations since last visit:
Pharmacy Name: Telephone #: ()--

Assignment of Insurance Benefits

* I authorize payment of medical benefits to T.L. Jenkins, M.D., P.A.

Authorization To Release Information

* I authorize T.L. Jenkins, M.D., P.A. to release any medical information as may be necessary for the complication of my insurance claim to any insurance carrier, health or hospital plan.

Acceptance of Financial Responsibility

* I accept financial responsibility for any services not covered by my insurance.

*Signature of Patient, Parent or Guardian:
Date :