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This form is not for health information, and I consent to my contact information being used to respond to my inquiry. My message will be sent to this clinic via unencrypted email. Do not include symptoms, diagnoses, medications, or other sensitive details.

Privacy and Sharing of Information I authorize Harmony health and Wellness, LLC and its associated health professionals to collect my personal and medical information as documented above while under their care. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission according to HIPPA requirements. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment and I may ask my provider for a more detailed explanation.