Please fill out and email this form to: email@example.com prior to your virtual visit. Also, please see the virtual visit section of the website for further instructions regarding virtual visits
Disclaimer: Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. Please do not include personal medical information in any emails you send to us. No one can diagnose your condition from email or other written communications, and communication via our website cannot replace the relationship you have with a physician or another healthcare practitioner.