Secure Contact Form

First name

Last name

Phone number

Clarity Together may contact me at this phone number:

Yes, and voicemails are okay Yes, but voicemails are NOT okay No

Email address

Clarity Together may contact me at this email address:

Yes No

If you selected yes, please check the appropriate boxes below:

I only wish to be contacted via secure communication means, or at the phone number provided, until such time as I may elect to make a request for communication via non-secure means.

Conventional email is inherently insecure and therefore poses a risk to the privacy and security of my Protected Health Information. I accept these risks and consent to Clarity Together communicating with me via unsecured email with regards to scheduling, billing, and payment for healthcare services. I am not required to give this consent in order to receive treatment.

Message

Your information will be encrypted.