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Request an Appointment - Pride Program

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We’re glad you’re here. If you are interested in LGBTQ+ primary care, including GAHT, you can schedule online with Dr. Safa here.

Otherwise, in order to get you registered and scheduled we will need to obtain some information from you. Please complete the questions below.

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 the Pride Patient Navigation number at 215-420-0989 or email lgbtq-pride@einstein.edu.

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What is your affirming name (i.e. the name you use/the name you go by)?
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What are your pronouns? (see Pronouns.org for resources on personal 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?
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What is your email address?
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What is your mailing address, including zip code?
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Do you have insurance?

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Are you under 18?

If yes, please answer the questions that appear below about the parent or guardian associated with your insurance.


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What is your current gender identity?
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What is your current sexual orientation?
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What kind of appointment/care are you looking to set up through Pride?
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Please give information about who we should contact in case of an emergency or crisis.

First name

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Emergency/Crisis contact:

Last name

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EmergencyCrisis contact:

Relationship to you

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Emergency/Crisis contact:

Phone number

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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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How did you find out about the Pride Program at Einstein?
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Are you interested in receiving more information about any of the following? (check all that apply)














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Are you of Hispanic, Latino/a/x/e, or Spanish origin?

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How would you describe yourself?
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What is your marital status?
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Do you identify with a certain religion? If so, what?
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Are you a Jefferson employee?

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What is your preferred method of communication? If phone, when are the best days/times to reach out?
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