Child Patient Intake Form (4-11)

Please keep in mind that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties or unauthorized individuals. Please do not include personal identifying information such as your birth date, or personal medical information in any emails you send to us. Communication via our website cannot replace the relationship you have with a physician or another healthcare practitioner.