RSVP 2 — Mercedes Kwiatkowski, MD

Prospective Patients

If you are seeking care with me for the first time, please fill out and submit the form below. I will contact you to provide a free phone consultation to determine if my practice is a good fit for your needs. We can then schedule an initial evaluation to begin.

I understand this form is not to be used for urgent or emergent medical or psychiatric concerns. For urgent or emergent issues, call 911 or go to the nearest Emergency Room.

Yes

Patient's Name

First Name

Last Name

Contact Email

Patient's Phone

(###)

###

####

Age of Patient

Mailing Address of Patient

Please tell me briefly about the patient and why they are seeking my services.

Is the patient seeking treatment for medication, therapy, or both?

Medication

Therapy

Both

Gender-affirming consultation

Who referred you to my practice? If not referred, how did you hear about my practice?

NOTICE TO PATIENTS OPEN PAYMENTS DATABASE

For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospital be made available to the public.

You may search this federal database for payments made to physicians and teaching hospitals by visiting this website:

https://openpaymentsdata.cms.gov/