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:
- Print out and fax to: (310) 829-5554
- Hand carry completed forms to Dr. Susko’s office
- Email the completed form to info@suskomd.com
Contact us if you have questions about any of our forms.
