Patient Forms

Littleton Gynecology & Wellness

Proudly Serving Littleton & Surrounding Areas

Patient FormWeb LinkPurpose / Description
New Patient Formsdownload form General information needed for each new patient... i.e - Name, Address, City, State, etc...
Credit Card on File Policydownload form

This form allows the office to keep a form of payment on file so that any balances unpaid by insurance can be promptly taken care of, eliminating the need for mailed in or phoned in payments.

Medical Records Releasedownload form

Allows you to give us the legal right to release sensitive Health Information to other health providers...

HIPAA Authorizationdownload form

This form grants us permission to discuss your medical care and/or leave phone messages regarding your care only (and ONLY) with the people you list. This includes your health information, laboratory results, test results & financial information.

HIPAA - Health Information Portability & Accountability Act
HIPAA Notice of Privacy Practicesdownload form This form describes how medical information about you may be used and disclosed and how you can gain access to this information.
Female Health Assessment Questionnairedownload form This female BioIdentical Hormone Questionnaire gives us both a good indication as to whether or not our RightBalance Hormone replacement therapy might be of help...
Male Health Assessment Questionnairedownload form This male BioIdentical Hormone Questionnaire gives us both a good indication as to whether or not our RightBalance Hormone replacement therapy might be of help...
Understanding your BMI Testing Resultsdownload form Understanding your BMI Testing Results gives you a much better indication as to whether or not our RightBalance Hormone replacement therapy might be of help...
Votiva Informed Consentdownload form Votiva Informed Consent form (required)
Votiva Self Assesmentdownload form This form helps you determine if this procedure is right for you...
Votiva Patient Instructionsdownload form Votiva Patient Instructions

(FormaV / FractoraV)

Call The Experts At Littleton Gynecology and Wellness Today!

At Littleton Gynecology and Wellness, we have been Littleton, CO’s first choice for women’s healthcare for more than two decades. We are dedicated and caring professionals who are committed to helping you with all your gynecological needs. From teen health through menopause and beyond, our experienced healthcare providers are committed to helping our patients achieve their most coveted health and wellness goals. Call our office today for safe and dependable health services.

“The superior doctor prevents sickness; The mediocre doctor attends to impending sickness; The inferior doctor treats actual sickness.” – Chinese Proverb