**IMPORTANT NOTICE:** Please refrain from submitting any sensitive medical information through this form. This includes but is not limited to, your medical history, current health conditions, and any other personal health information.

Please be aware that the submission of this form does not establish a doctor-patient relationship, nor does it constitute the provision of medical advice or treatment.

This form is intended solely for general inquiries and information. If you require medical advice, please call our office directly and make an appointment. If you require immediate or emergency attention, call 911 or your local emergency number or go directly to an emergency room.