ETSU OB/GYN Teaching Physicians

You will be seen by a physician who is a member of the faculty of the James H. Quillen College of Medicine. The physicians, who work in this office, as part of their faculty responsibilities, are responsible for teaching medical students and residents (post graduate trainees). Our mission here is dual: Caring for patients and teaching students and residents. Not only will you see your own physician here, but you may also be seen by one or more medical students and residents. This is part of the mission of the College of Medicine. We believe this adds to the depth and level of care the patient receives, since patients are seen by one or more physicians and discussed in detail. Several thousand patients receive their medical care through our office and enjoy helping our teaching programs. We are pleased with your willingness to participate in our teaching program and your care shall encompass a team approach to health care with involvement of your physician, residents, medical students and other medical trainees. ____________________ Date ____________________________________________ Signature of Patient or Responsible Party

-----------------------------------------------------------------------------------------------------------No Show Policy

The policy of ETSU OB/GYN requires an advance notice for appointment cancellations. Although many scheduling conflicts occur from time to time, we ask that you please notify our office of any cancellations prior to your appointment time. A patient is considered to have missed an appointment should they fail to appear without prior notification or arrive later than 15 minutes of the scheduled appointment time. We know that your time is valuable; therefore, we would ask that you please arrive at least 20 minutes before your scheduled appointment time so that your information may be verified promptly. In order to provide the standard of care ETSU OB/GYN prides itself on, it is important that scheduled appointments are not missed, without prior notification, which would allow us to reschedule the appointment at a more convenient time that suits your needs. Should you miss three or more appointments within one year, you can be dismissed from our office; however this is an event that we would certainly like to avoid. Your signature below indicates that you have read and understand our policy, as outlined above. ____________________ Date ____________________________________________ Signature of Patient or Responsible Party

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Release of Medical Information

I am giving ETSU OB/GYN permission to release my medical information to the following individual(s), should there be a need:

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Signature of Patient or Responsible Party