Caring for Women of All Seasons

Patient Forms

At Tania White Jackson, M.D., P.A, we partner with you to ensure that the obstetrical and gynecological care you receive is the very best. We’ve provided the resources below to make your first visit as comfortable and convenient as possible. Download new patient forms, learn about our insurance and billing process and read our mission statement — then call us to schedule an appointment! [xyz-ihs snippet=”ZocDocs”]

New Patient

Patient Profile Form

Personal Intake History Form

Consent Form

Medical Records Release Authorization

Obtain Medical Records Authorization

Existing Patient

Patient Profile Form

Interval History Form

Consent Form

Complete Forms Library- Click Here

Get Prepared For Your Visit

In order for us to provide the best care for you, it is very important that you bring the following items to your visit:

  •     Photo ID
  •     A list of your current medications
  •     Insurance information and card
  •     Information about what treatments and medications have been tried in the past
  •     Medical records from prior visits that you think may be helpful
  •     New Patients: download a patient registration below

Patient Forms

Before your appointment with us, quickly and conveniently access patient forms from our practice.
Get Adobe AcrobatTo view the forms listed below, you will need Adobe Reader. You may download Adobe Reader for free at Please bring your completed forms with you to our office at the time of your visit.

We may ask you to complete a form and bring it with you to your appointment. Click on the appropriate link and download the form.