Dear Patient: Thank you for making a reproductive genetic ...

Division of Medical GeneticsDepartment of Genetics andGenomic SciencesMailing address:One Gustave L. Levy Place, Box 1497New York, NY 10029-6574Patient Address:1428 Madison Avenue (at 99th Street)New York, NY 10029Dear Patient:Thank you for making a reproductive genetic counseling appointment at the Mount Sinai MedicalCenter.Please complete the attached forms and bring them to your appointment. Please note that the familyhistory questionnaire includes one page for the female member of the couple and one for the malemember of the couple (if applicable). At the time of the genetic counseling session, we will review theinformation that you have provided and address all relevant issues. If a complex genetic counselingissue is identified, we will assist you with scheduling a follow-up genetic counseling session in order tothoroughly discuss that issue.For patients planning to have a CVS or amniocentesis procedure, please refer to the instructions specificto that procedure.Thank you very much for your cooperation. We look forward to working with you.Sincerely,Randi E. Zinberg, M.S. Julie McGlynn, M.S. Jane Robinowitz, M.S.Genetic Counselor Genetic Counselor Genetic CounselorYara Kharbutli, M.S. Michelle Cahr, M.S. Leah Blanchard, M.S.Genetic Counselor Genetic Counselor Genetic Counselor

Do you (female partner) have a personal or family history of any of the following? When considering family members,please include your children, brothers, sisters, parents, aunts, uncles, cousins, and grandparents.*Please inform your genetic counselor/physician if you/your partner are adopted or if you are pregnant and a sperm/ovum donor was used to conceive thepregnancy.Personal/Family History of: No Yes (please specify)Down syndrome or other ChromosomalAbnormalityMental Retardation or Severe DevelopmentalDelayFragile X syndromeCongenital Spine or Brain DefectCongenital Heart DefectCongenital Kidney DefectBlindness/DeafnessCleft Lip and or Cleft PalateOther Serious Birth Defect(s)Muscular DystrophyCystic FibrosisSignificant family history of commonconditions such as cancer or heart disease (i.e.people who were diagnosed at a young (

Do you (male partner) have a personal or family history of any of the following? When considering family members,please include your children, brothers, sisters, parents, aunts, uncles, cousins, and grandparents.*Please inform your genetic counselor/physician if you/your partner are adopted or if you are pregnant and a sperm/ovum donor was used to conceive thepregnancy.Personal/Family History of: No Yes (please specify)Down syndrome or other ChromosomalAbnormalityMental Retardation or Severe DevelopmentalDelayFragile X syndromeCongenital Spine or Brain DefectCongenital Heart DefectCongenital Kidney DefectBlindness/DeafnessCleft Lip and or Cleft PalateOther Serious Birth Defect(s)Muscular DystrophyCystic FibrosisSignificant family history of commonconditions such as cancer or heart disease (i.e.people who were diagnosed at a young (

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACYPRACTICES (NOPP)By signing below, I acknowledge that I have been provided a copy of this Notice ofPrivacy Practices and have therefore been advised of how health information about memay be used and disclosed by the hospitals and the facilities listed at the beginning ofthis notice, and how I may obtain access to and control this information_________________________________________Patient Name_________________________________________Signature of Patient or Personal Representative______________________________________Print Name of Patient or Personal Representative_________________________________________Date_________________________________________Description of Personal Representative’s AuthorityI was not able to obtain the patient’s acknowledgement of receipt of the NOPP uponregistration because:ooooThe patient refused to sign despite good faith effortsThe patient was unaccompanied and not alert and orientedThe patient was unaccompanied and needed emergency careOther,( explain): _________________________________________Employee Signature: _________________ Employee Title: _________________Print Name: ______________________Date: __________________________oAcknowledgement subsequently obtained, (see above).MR-205 (Rev 5/04))

CONSENT FOR COMMUNICATION VIA E-MAIL (Provider-Patient)I, _______________, hereby consent to have my physician, _____________,communicate with me or members of his staff, where appropriate or otherphysicians, nurse practitioners and pharmacists via e-mail regardingthe following aspects of my medical care and treatment: [test results,prescriptions, appointments, billing, etc.]. I understand that e-mailis not a confidential method of communication. I further understandthat there is a risk that e-mail communications between my physicianand me or members of my physician’s office staff, or between myphysician and other physicians, nurse practitioners and pharmacistsregarding my medical care and treatment may be intercepted by thirdparties or transmitted to unintended parties. I also understand thatany e-mail communications between my physician and me or members of hisoffice staff, or between my physician and other physicians, nursepractitioners or pharmacists regarding my medical care and treatmentwill be printed out and made a part of my medical record. I understandthat in an urgent or emergent situation I should call my provider or goto the Emergency Room and not rely on e-mail.Signature:_______________________Date: _________________E-mail Address: __________________________________________MR-240 (9/03)