I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form. By submitting this form, you consent to receive SMS messages from the practice. Please note that your number will not be shared with third parties or affiliates for marketing purposes under any circumstances.