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Tomeka Robert M.D. P.C


  Last name

  Mid name

  First name

Today's Visit

THE DOCTOR YOU ARE HERE TO SEE IS: Dr. Roberts Dr. Jones
My primary insurance is Medicare My primary insurance is not Medicare
What is the purpose of your visit today?
Annual Exam Only – I am here for my “annual wellness examination” which will include a physical exam and may include a pap smear and mammogram. I require no other testing or evaluation other than a renewal of my current maintenance medications which have been prescribed here in the past.
Annual Exam and Other Reason – I am here for my “annual wellness exam” but I also have a problem, complaint or issue that I need to have evaluated/discussed or I may require a new prescription. I understand that my insurance will require a co-pay for any of these additional evaluations or where a new prescription is given.
Office Visit – I am not here for my “annual wellness exam” but for a problem, complaint, or recheck that I need evaluated or I am requesting a new prescription. I understand that my insurance will require that a co-pay be made for these services.
Post Partum /Post op visit
Yes No
Yes No
Yes No

Insurance Information


Do you have any changes in your insurance? Yes No
Contract No : Group No: 
Relationship: Date of Birth: 

Appointments, No Show and Cancellation Policy


If you are unable to keep your appointment, we ask that you kindly provide us with at least 24 hours’ notice. A $50 fee may be assessed to your account if you do not show up for your appointment without notice or if we receive a cancellation of less than 24 hours.
It is the patient’s responsibility to remember her appointment. The courtesy call that the staff will make in the future is not designed for nor should be used as an appointment reminder.

Thanks,
Management

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Date:
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