Hospital Affiliation
New Patient Forms and Privacy Notices
Below are all the forms needed for your appointment. Please take a moment to print and fill out each form completely. You may mail them to the office before your appointment or bring them with you on the day of your appointment. Please have these forms completed before you arrive. Failure to have all forms completed could delay the check-in process.
Patient Registration Forms
- Complete Registration Packet
- Welcome to Heartland Women’s Group
- Patient Demographics
- Medical History
- Consent Form
- Financial Policy
- Record of Disclosures
- HIPAA Acknowledgement
- Release of Records from Heartland Women's Group
- Release of Records to Heartland Women's Group
Patient Instructions
- Patient Instructions – Ultrasound
- Medications in Pregnancy
- Insurances We Accept
- Essure Procedure – Frequently Asked Questions
- Prolapse Surgery - Frequently Asked Questions
- In-Office Ablations - FAQ
Maps
Billing Statements
If you have questions about your account, please contact us at 1-888-422-7720. Assistance is available from 7:00 AM to 5:30 PM CST, Monday through Friday.
Privacy Practices
These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here:
(this link opens a new browser window).
Tell us how Dawne Lowden, MD; Melissa Hague, MD; James Whiddon, MD; Kelli Wehling, ARNP; and Amanda Twist, PA are doing by clicking below.
Tell us how Bruce Bammel, MD; Michael Jackson, MD; Hilary Rainbolt, MD; and Katie Sutton, MD are doing by clicking below.
Please let us know how we're doing at our new West Side office by clicking below. Thanks!
