Date of Birth *

Preferred Date *

Preferred Time *

I understand and agree that any information submitted will be forwarded to the practice by email and not via a secure messaging system. There is some risk that unsecured email transmissions could be read or otherwise accessed by a third party while in transit. I accept any risk of compromise. I further understand that this form should not be used to transmit private health information. I also understand that I am able to make appointments by calling the practice directly. The practice is not responsible for any breach of my information that occurs during transit and specifically disclaims all warranties with respect to the privacy and confidentiality of any information submitted through this form. *