Forms

Forms-New Patient Packet

Form Number Form Name Form
1. ABN Telephone Consult Download
2. Acknowledge of Receipt of Notice of Privacy Practice Download
3. Appointment No-Show & Cancellation Policy Download
4. Authorization to Release Medical Records Download
4. Authorization to Release Medical Info Download
5. Consent to Obtain External Rx History Download
6. Credit Card Authorization Form Download
7. Financial Agreement Download
8. Medication List Download
9. Patient History Form Download
10. Patient Registration Form Download
11. Pharmacy and Referring Physician Information Download
12. Welcome Letter Download

 

Please note the following ways you can submit these forms to Dr. Susko’s Office:

  1. Print out and fax to: (310) 829-5554
  2. Hand carry completed forms to Dr. Susko’s office
  3. Email the completed form to info@suskomd.com

 

Contact us if you have questions about any of our forms.