We will only use the information you provide on this form to respond to your inquiry and provide relevant services. We will not share your personal information with third parties without your permission, except as required by law”
This form is not a secure method of communication and should not be used to submit confidential medical information. Under the Health Insurance Portability and Accountability Act (HIPAA), we are required to protect your personal health information (PHI). For your privacy and protection, please do not include sensitive details such as:
Medical records or test results
Diagnosis or treatment information
Prescription details
Social Security numbers or insurance ID numbers
If you need to discuss your medical care or share personal health information, please call our office directly at [phone number] or use our secure patient portal (if applicable). In the event of an emergency, dial 911 immediately.
Use of Information
By submitting this form, you understand and agree that the information you provide will be used only to respond to your inquiry. While we make every effort to safeguard your data, electronic communication may not always be secure. Submitting this form does not create a physician–patient relationship.