Michigan Medicine Medical Record Number: _______________ If you don't know your MRN, leave this field blank.
Legal first name: _________________________ Legal last name: __________________________
Date of Birth: _______________________
Current legal sex: F M
Trans man
Man
Nonbinary
Other: __________
Gender:
Use my name
Pronouns:
She/her
He/his
They/them
Other: _______________
Race/Ethnicity: _______________________
Address: _________________________________________________________________________
City, State, Zip: ____________________________________________________________________
Preferred phone number: __________________________ OK to leave message? Yes No
Alternate phone number: __________________________ OK to leave message? Yes No
Best days/times to call: ____________________________
Email address: ________________________________________
Type: Home Mobile Work Other _________________
Type: Home Mobile Work Other _________________
Date: ___________________
Trans woman
Woman
Genderqueer
Two spirit
PLEASE READ THIS SECTION
If you provide your preferred name, gender identity, and pronouns on this form, we will add this information to your
electronic medical record. This information will be available to all health care providers and staff using the Michigan
Medicine electronic medical record system. It is your choice whether or not you provide the information in this
box, below. If you provide the information:
•
Providers, staff, and automated systems (including automated appointment reminders) should use your preferred
name when communicating with you.
• Office visit notes from Michigan Medicine providers should include your preferred name and pronouns.
• Clinic staff may use your preferred name when they call you from a waiting room.
• Your gender identity will appear in addition to your legal sex at various places in your chart.
• If you receive care from a non-Michigan Medicine hospital or emergency room that can access Michigan Medicine’s
electronic medical record, that other health care system may see your preferred name, pronouns, and gender identity.
• If a Michigan Medicine provider refers you to a non-Michigan Medicine facility, your preferred name and gender
identity may appear along with your legal name and sex.
You may leave any part of this section blank.
Preferred first name: ______________________ Preferred last name: _______________________
ADULT SERVICE INQUIRY FORM
By returning this completed form, you consent to this information becoming part of your electronic
medical record at Michigan Medicine.
Please make sure that your answer to this question matches your legal sex according
to your insurance provider.
