Patient Information Form

Please correct the errors described below.

Welcome to the office of Dr. Marla Kushner! We are looking forward to helping you with your healthcare needs. Please carefully review, initial, and sign these policies and procedures.

Basic Biographical Information

First:

MI:

Last:

Marital Status:

Single Married Partnered Divorced Widowed

Pronouns:

He/His She/Her They/Them

Other:

Sex at Birth:

Gender Identity:

Birthdate:

Social Security No:

Address:

City:

State:

Zip:

Occupation:

How did your hear about us?

Emergency Contact:

Name:

Phone:

Relationship to you:

Communication

Please check your preferred contact method below:

Cell Phone:

Home Phone:

Work Phone:

Email:

By providing us with the above information, you authorize us to call, leave voicemails, and send text messages using the above information for non-marketing purposes, including appointment reminders, billing and invoice updates, and treatment questions. You further understand and agree that communication with us by unencrypted emails and text messages may not be secure.

I acknowledge and agree to this Communication Policy

(initial)

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

Electronic signature

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I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

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