Signature Page with E-mail Policy

After you have reviewed the Office Policies and the Privacy Policy, please feel free to contact Dr. Queenan with any questions or concerns. When you are comfortable with these policies, please download, print, and sign the Signature Page with e-mail policy below. Please bring this form with you to your first appointment.

Download printable Signature Page here

Acknowledgement of Office Policies, E-mail policy, and Privacy Policy

1. I have read the information about e-mail procedures and privacy and have received answers to all of my questions about using e-mail to communicate with Dr. Emily Queenan.

2. I understand that e-mail is never appropriate for urgent or emergency situations.

3. I understand that e-mails sent to Dr. Queenan from any email address, other than a Onebox email address, are considered insecure and I assume all responsibility for any misuse or misdirection of personal health information contained in such e-mails.

4. I have read the Office Policies of Queenan Family Medicine and Maternity Care and have received answers to all of my questions regarding the contents therein.

5. I have read the Notice of Privacy Practice for Protected Health Information (above) of Dr. Emily Queenan and have had all of my questions answered regarding the contents therein.

Signature: _______________________________________ Date: __________________

Print Name: _____________________________________________________________

Date of Birth: ________________________