New Patient Registration

Patient Registration

Lystra Wilson-Celestine, MD/MPH
Patient Information
Name

First NameMiddle NameLast Name
Previous Name
Sex
Date of Birth

MonthDayYear
Marital Status:
*Optional
Address:

Street Address

Apartment, Suite, Unit, P.O. Box, etc.

CityState / Province

Postal / Zip Code
Phone Number:
Format: (000) 000-0000.
E-mail:
example@example.com
Contact Preference
How Did You Hear About Genesis?
Primary Care Physician, Online Source, Family, etc.
Primary Care Provider
Provider Phone Number:
Format: (000) 000-0000.
Language
Race:
*Optional
Ethnicity:
*Optional
Employer Information (if currently employed)
Employer:
Work Phone Number:
Format: (000) 000-0000.
Occupation:
Emergency Contact Information
Emergency Contact: #1

First NameLast Name
Contact Number:
Format: (000) 000-0000.
Relationship to Patient:
Emergency Contact #2:

First NameLast Name
Contact Number:
Format: (000) 000-0000.
Relationship to Patient:
Primary Insurance

*Please bring card with you to office*
Insurance Plan Name:
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Member ID:
Group No.
Policy Holder's Full Name:

First NameMiddle NameLast Name
Policy Holder DOB:

MonthDayYear
Policy Holder's Sex
Patient's relationship to Policy Holder:
Insurance Provider Phone Number:
Format: (000) 000-0000.
Secondary Insurance
Insurance Plan Name:
Effective Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Policy Member ID:
Group No.
Policy Holder's Full Name:

First NameMiddle NameLast Name
Policy Holder DOB:

MonthDayYear
Patient's relationship to Policy Holder:
Insurance Provider Phone Number:
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Guarantor Information (to whom statements are sent, if other than self)
Guarantor Information

First NameLast Name
Relationship to Patient
Phone Number:
Format: (000) 000-0000.
Address:

Street Address

Apartment, Suite, Unit, P.O. Box, etc.

CityState / Province

Postal / Zip Code
Cancellation and No-Show Policy
When you schedule an appointment at Genesis Center for Women's Health, we set aside enough time to provide you with the highest quality care.

If you need to cancel or reschedule an appointment, please contact our office as soon as possible no later than 24 hours prior to your scheduled appointment.

Please see our policies detailed below.

Effective Date: December 20th 2021 (Revised September 28, 2026)

1. Established Patients Fee: Any established patient who fails to show or cancel/reschedule an appointment without providing at least 24-hour advance notice will be considered a no-show and will incur a charged fee of $125. This fee is charged directly to the patient (not covered by insurance) and is your financial responsibility.

2. Patient Dismissal: After three (3) no-shows, cancellations, or reschedules without 24-hour notice the patient may be dismissed from Genesis Center for Women's Health.

3. New Patients: Any new patient who fails to show for, cancel, or reschedule their initial appointment will be offered a second opportunity to be seen upon request. After a second no-show, cancellation, or reschedule without the appropriate notice, the patient will no longer be eligible to schedule
future appointments.

4. Access to Care: Adhering to this policy allows us to maintain availability for patients who may have urgent care needs.

5. Appointment Reminders: We maintain a courtesy automated reminder system. However, its is your responsibility of manage the appointments that you have scheduled.

10-Minute Late Policy
We want to make the most of your appointment time, which is why we enforce a strict 10-minute late policy. This policy is necessary to allow our providers to run on time and remain respectful of other scheduled patients. We will do our best to also respect your time and make all attempts to see you at your scheduled time.

If you arrive more than 10 minutes past your scheduled time, we will need to
reschedule your appointment for another day. The decision will be made based on appointments availability.

Extenuating Circumstances
We understand that unforeseen emergencies may prevent you from attending your scheduled appointment or from us seeing you at the scheduled time. If you experience extenuating circumstances, please contact our office as soon as
possible. Under appropriate circumstances, management may be willing to waive the no-show. We will also keep you informed as to whether there any any circustances that will impact the time you will be seen by our Providers.

Phone Line Hours:
Monday – Friday: 8:30 AM – 11:45 AM 1:00 PM – 4:30 PM
Office Phone: 279-886-9000

Gabby our AI Receptionist will be happy to support you during your phone call.

Voicemail is available after hours and on weekends for your convenience.
Please review and check each of the required boxes
I First Name* Last Name*, hereby authorize Genesis Center for Women’s Health, Inc and its affiliates, its employees and agents, to use and disclose protected health information (e.g., information relating to the diagnosis, treatment, claims payment, and healthcare services provided or to be provided to me and which identifies my name, address, social security number, member ID number) for the purpose of helping me to resolve claims and health benefit coverage issues.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty:

Patient Registration

Patient Information

Employer Information (if currently employed)

Emergency Contact Information

Primary Insurance

Secondary Insurance

Guarantor Information (to whom statements are sent, if other than self)

Cancellation and No-Show Policy

When you schedule an appointment at Genesis Center for Women's Health, we set aside enough time to provide you with the highest quality care.

If you need to cancel or reschedule an appointment, please contact our office as soon as possible no later than 24 hours prior to your scheduled appointment.

Please see our policies detailed below.

2. Patient Dismissal: After three (3) no-shows, cancellations, or reschedules without 24-hour notice the patient may be dismissed from Genesis Center for Women's Health.

4. Access to Care: Adhering to this policy allows us to maintain availability for patients who may have urgent care needs.

5. Appointment Reminders: We maintain a courtesy automated reminder system. However, its is your responsibility of manage the appointments that you have scheduled.

If you arrive more than 10 minutes past your scheduled time, we will need toreschedule your appointment for another day. The decision will be made based on appointments availability.

If you arrive more than 10 minutes past your scheduled time, we will need to
reschedule your appointment for another day. The decision will be made based on appointments availability.