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Our staff will get back

you you as soon as possible

Please provide information about yourself

and your preferred appointment time.

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

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