Email Consultation Form

Thank you for your interest in an email consultation with your DBC doctor. The doctors will check for consultation requests during the middle of their day, and respond within one business day, based on their office schedule. In the case the doctor requires a face-to-face appointment, rather than an email response, to best serve your needs, your $15 payment will be applied to the appointment charge.


Your Informed Consent
I will be happy to respond to your query but to do so via e-mail you must provide your consent, recognizing that e-mail is not a secure form of communication. There is some risk that any protected health information that may be contained in such e-mail may be disclosed to, or intercepted by, unauthorized third parties. I will use the minimum necessary amount of protected health information to respond to your query.

If you wish to conduct this discussion via e-mail, please indicate your acceptance of this risk by selecting “I agree to the Informed Consent”. Alternatively, please call the office to arrange a phone consultation or office visit.

I agree to give consent
CONTACT INFORMATION

Patient Name

Email address

Confirm Email address

Daytime Phone #

BILLING INFORMATION

Name (as appears on credit card)

Credit Card Number Visa Discover MasterCard

Expiration Month

Expiration Year

Security Code

Billing Address

City

State

Zip

CLINICAL INFORMATION

Doctor

Question(s) for the Doctor

Entry limit 500

Current Supplements (include quantity)

Last Appointment

(MM/DD/YYYY)