Responsible Party *

First Name

Last Name

Patient to be Treated Name

First Name

Last Name

Date of Birth *

DOB of Patient being Treated

MM

DD

YYYY

Phone *

(###)

###

####

*

Disclosure: In accordance with federal laws, we are committed to maintaining the security and confidentiality of all personal and medical information provided by our patients. Your privacy is of utmost importance to us. By submitting this form, you acknowledge and consent to the following: We will collect and use the information provided in this form solely for the purpose of initiating contact and providing you with the requested information. Any additional information shared beyond what is required will be collected and treated as confidential, subject to your proper authorization. While we take every precaution to ensure the security of our online systems, please be aware that submitting information through this website or patient portal carries inherent risks associated with electronic communication, including but not limited to unauthorized access or interception by third parties. By checking the box below, you indicate your understanding of the risks involved and provide your consent to submit the information filled out in this form. Consent to Communicate via Patient Portal: By checking the box below, you also give your explicit consent for us to communicate with you through our secure patient portal. This includes the exchange of personal and medical information, appointment reminders, test results, and other pertinent communication related to your healthcare. By checking the box, you acknowledge that you have read, understood, and agree to the above disclosure and consent.

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