WOODSON C. MERRELL, M.D. PLLC 44 EAST 67th STREET NEW YORK, NEW YORK 10065 Telephone: (212) 535-1012 Fax: (212) 535-1172 Checklist for New Patient Inquiries Date: Name: Age: DOB: Address: Phone: Email: Referred by: Current Primary Physician: Chief Complaints: Brief Medical History: EFTA00296174