Signature Page

Please print this page and bring it with you to your New Patient Appointment.

  1. I have read the information above about email procedures and privacy and have received answers to all of my questions about using email to communicate with Steward Family Medicine.
  2. I understand that email is never appropriate for urgent or emergency situations.
  3. I understand that emails sent to Dr. Steward from any email address other than a onebox secure email address is considered insecure and I assume all responsibility for any misuse or misdirection of personal health information contained in such emails.
  4. I have read the Practice Policies of Steward Family Medicine and have received answers to all of my questions regarding the contents therein.
  5. I have read the Privacy Practice for Protected Health Information policy of Steward Family Medicine and have had all of my questions answered regarding its contents.

Patient Name (Please Print):

Patient's Date of Birth (MM/DD/YYYY):

Patient's Signature and Date Signed: