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Request an Appointment - Pride Program

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We're glad you're here. In order to get you registered and scheduled we will need to obtain some information from you. Required questions are for our medical records system and for billing purposes we need to collect this information. All other questions are optional.

If you’re not ready to register for an appointment now, or you would like to talk to the Pride patient navigator about the Pride Program or Einstein in general, please call Eliza (they/them) at 215-420-0989 or email lgbtq-pride@einstein.edu.
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What is your affirming name (i.e. the name you’d like us to call you)?
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What are your pronouns?




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Do you require an interpreter?

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What is your date of birth?
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What is your telephone number?
What is your email address?
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What is your mailing address?
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What is the name on your insurance card?
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Do you have insurance?

What is your current gender identity?













What is your current sexual orientation?









How do you identify your race?







Would you like to receive emails about Pride workshops and community events, about once every 3 months? (We won't send you any other emails)
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In case of an emergency or crisis, who should we call to support you?

Please list their name, pronoun(s), contact information, and relationship to you.
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How did you find out about the Pride Program at Einstein?
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What kind of appointment/care are you looking to set up through Pride?
Are you interested in receiving more information about any of the following?














SUBMIT
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