☎ (706) 543-6261 LOCATIONS ABOUT US PATIENT RESOURCES We Are Delighted To Welcome You To Our Practice We would like to take this opportunity to welcome you as a patient. It is our desire to make your visit smooth and efficient. We thank you in advance for your cooperation. To facilitate your appointment, we ask that you please take a few moments and complete the forms below. The doctor cannot see you until this information has been filled out and entered into our EMR system. If you have not completed the forms prior to your visit, please come 30 minutes before your scheduled time. Please return the completed forms via mail or in person to our Athens office, or by fax (706) 543-7060. We need you to bring the following to your appointment: Insurance cards Driver’s license or picture ID Insurance copay List of medications and allergies (please bring an updated list to every appointment) CD disk of x-rays or labs if performed, relating to your current problem If you have been referred to our practice and your insurance requires a referral from you PCP, please contact your PCP and make sure that they get the proper paperwork to us. Please check with us in advance to ensure it has been received. Failure to have a referral upon arrival will result in rescheduling your appointment. Please also note that any payments and copays not covered by your insurance carrier will be due at or before time of service. Thank you, Dr. John Blankenship DOWNLOAD PDF OF NEW PATIENT FORM HERE Our forms are designed and encrypted to collect your health information safely and securely from any device. If you are unable to complete the form digitally, please call our office to have a paper copy sent to your home, or download it as a PDF in the orange link. MORE ABOUT OUR NURSE PRACTITIONERS SERVING GEORGIA’S NORTHEAST CORRIDOR WITH OFFICES IN ATHENS & ROYSTON HOME | ABOUT US | AREAS OF PRACTICE | LOCATIONS 706-543-6261 | UGofA.frontdesk@gmail.com 195 King Avenue | Athens, Georgia | 30606 FAX: 706-543-7060 It is our mission to provide the highest quality, compassionate and skilled urological care to enable people to stay healthy and be well. “Where the human side of healthcare is here to stay”