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*This form is not HIPAA compliant-see privacy notice below.

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*Please include if you would like an invitation to the patient portal for scheduling.

 

*Please note that this form is NOT HIPAA-compliant and is NOT secure for transmitting confidential medical or mental health information. Do NOT include confidential medical details, symptoms, or private health information in this inquiry form. This form is for general inquiry and administrative purposes only. This form is NOT monitored 24/7 and is NOT for urgent/emergent inquiries. If you are having a mental health or medical emergency, see the Emergency Disclaimer below.

 

By submitting this form, you acknowledge and accept that the communication is not encrypted or protected under HIPAA.

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Emergency Disclaimer: This form is NOT monitored 24/7 and is NOT for medical or mental health emergencies. If you are experiencing a medical or mental health emergency, please call 911 or go safely to the nearest emergency room. The 988 Suicide and Crisis Lifeline is also available 24/7 by calling or texting 988.

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