BY CLICKING SUBMIT YOU ARE AGREEING TO THE FOLLOWING TERMS AND CONDITIONS
 

This form will be sent to My Home Doctor via email. I understand that email is a convenience and not appropriate for

emergencies or time-sensitive issues. Additionally, I understand that the security and privacy of e-mail cannot be guaranteed. Further, I understand that e-mail should not be used to transmit highly sensitive or personal information.

With regard to my protected health information, I understand that My Home Doctor can send unencrypted emails ONLY if I am advised of the risks. I understand My Home Doctor are not responsible for information lost due to technical failures. I understand that all of the information contained in and or attached to electronic messages is privileged and confidential and is covered by the Electronic Communications Privacy Act, 18 U.S.C. § 2510-2521.
I consent to e-mail communication with My Home Doctor