All of our on-line forms are created and kept secure via G-Suite, with whom we have signed a HIPAA Business Associate Agreement.  If you would like to read more about how G-Suite keeps your information private and secure, please refer to this page.

While unlikely, I accept that a breach of my privacy could occur when sending this information over the internet and/or when communicating by email and I am willing to accept that risk. I also understand that I have the option of printing this form and faxing it in or calling the office. 

Alternatively, you may print and complete the form and bring to your appointment‬.