If possible, please print these files, fill out the appropriate forms (new patient database and either adult or pediatric medical history, page 4 (signature page) of the HIPPA Privacy Policy, and email consent if that form of communication is desired), and bring them with you to your visit. Completing the forms prior to the visit will allow more of the your time in the office to be spent on matters that are important to you.  Alternatively, we can provide forms for you in the office. 

E-mail consent (must review and sign this form if you desire to communicate with Greene Family Medicine, PLLC via email)

HIPAA Privacy Policy

PHI Disclosure (use this form if you would like me to share your protected health information with another individual, ie. a family member)

Legal Disclaimer

New Patient Database (please complete this form prior to your first visit/  tip:  the "person responsible for the bill" should be the insured person or the person carrying the health insurance policy/ please be sure you designate Dr. Ketzak as your PCP prior to your first visit if a PCP or "primary care physician" is required by your insurance)

Adult Medical History (18+)

Pediatric Medical History (0 - 17 years)