Patient's Name	Patient's Date of Birth
Phone Number	Parent / Guardian (If Under 18)

Message

To verify that you are human, please enter the code you see in the image on the left into the box below.

Due to HIPPA privacy laws, we will not email you a response in order to protect the privacy of our patient. If your question is regarding someone other than yourself, you must have on file in our office documentation indicating that you have permission from the patient to receive protected health information on their behalf. This form can only be filled out in our office by the patient in front of our staff. The exception to this is a parent calling about their child who is under the age of 18. If we determine that you have permission to receive protected health information, we will call you back at the telephone number you provide within 1 business day. If you are not sure if you are on file to receive protected health information, it is suggested that you call us at 517-448-8918 to ask your question. Thank you.