The How Clinic Intake Form

What type of birth control are you using?
Are you currently using any type of hormone replacement?

YesNo
What type of hormone replacement are you currently using?
SMS appointment messaging: Please let us know if you would like to opt out of text message reminders for appointments and / or communication.

Opt out
Email newsletter: Do we have your permission to send emails regarding new services and updates?*

YesNo
Today's Date*

MonthDayYear
I,*

First NameLast Name
give my express permission to The How Clinic and John How, M.D. to obtain, and access to all of my medical records (with any exceptions or limitations listed in next section). I understand that my personal and medical information may be stored on a password protected secure cloud service.
Any exceptions or limitations to medical record access:
I give my permission to share medical records information to this specified individual.

First NameLast Name
I have received a copy of the HIPAA Notice of Privacy Practices.
Patient Name*
Today's Date*

MonthDayYear
Signature*

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Patient Information and History