"*" indicates required fields What is your message about?*Select one.Appointment SchedulingBilling and PaymentsReferral RequestsOtherPlease select an option so that we can best help you. Please call the office. Personal, private or protected health information matters must be addressed over the phone.HiddenContact Info SectionName* First Last Email* Phone*HiddenScheduling SectionI wish to…* Request a new appointment Inquire about an existing appointment Other You will be redirected to complete your appointment request once you select “Submit”.HiddenBilling and PaymentsDo you have a question about a specific statement or bill?* Yes No Service Date or Statement Number* HiddenMessage SectionMessage*HiddenWaiver SectionWaiver*I acknowledge that I am not including any protected health information (PHI) in my inquiry. I understand that any such information should be presented in person or securely over the phone with my health care provider. PHI, as defined by HIPAA (Health Insurance Portability and Accountability Act) includes, but is not limited to, any information that relates to 1) the past, present, or future physical or mental health or condition of an individual, 2) the provision of health care to an individual or 3) the past, present, or future payment for the provision of health care to an individual that identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual. I consent to allow any and all electronic communications with this recipient. These communications include this form and all others on this website, emails, text messages and website comments. I understand that electronic communication is not secure and that any information that I provide here may be visible to third parties or unintended recipients. I waive my rights under HIPAA to the extent that they can be waived and, in the event that any PHI is provided within this message or related messages, do not hold the recipient liable to any breaches or disclosures of the information provided in this message. I acceptCommentsThis field is for validation purposes and should be left unchanged.