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Privacy Notice: Please use this form only for general consultation requests. Do not submit medical records, diagnoses, treatment information, wound photos, Social Security numbers, insurance/member IDs, financial information, or other sensitive personal or health information. This form is not intended for the transmission of Protected Health Information (PHI) or emergency medical concerns.

By submitting this form, you confirm that the information provided is limited to general contact and consultation-request information and, if submitting on behalf of another person, that you are authorized to do so. You are responsible for the accuracy and appropriateness of the information you choose to submit. Submitting this form does not establish a patient-provider relationship or guarantee acceptance for services.

For confidential health information or medical records, please call (656) 200-7940 so we can provide an appropriate secure method of communication. For medical emergencies, call 911.