Patient Center

Please download, print and complete the forms below. Forms can be faxed to our office at (317) 647-4242, or brought to your first appointment.

Forms

Patient Demographics Form

Please complete and bring this Patient Demographics Form to your first appointment to help make your office visit as smooth as possible.

Patient Medical History Form

Please complete and bring this Patient Medical History Form to your first appointment to help make your office visit as smooth as possible.

Records Release Form

Please complete and bring this Records Release Form to your first appointment to help make your office visit as smooth as possible.

Referral Form

Please complete and bring this Referral Form to your first appointment if you have been referred to Integrative Gynecology, MD from another provider.

Menopause Questionnaire

Please complete and bring this Menopause Questionnaire only if you are being seen for perimenopausal or menopausal symptoms, or hormone replacement therapy.