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Disclaimer: If you request an appointment or submit any other information online through our secure form, all your information is transmitted to our email system and is held in strictest confidence. Briefly describe your problem in the field above and we will gather all other necessary information either at our office, over the phone or from your patient forms. Please do not submit any confidential information through this form, which may include your social security number, insurance information or any credit card/payment information. By submitting information through this form you acknowledge, read and accept this disclaimer as our practice remains HIPAA compliant.