- I give permission for Dr. Lenoir NOW to use the information I supply on this form to fulfill my request for a physician appointment and to contact me by email if necessary using the email address I supply on the form.
- I certify that I am at least 18 years old and I acknowledge that I have read and accept these terms and agree to use this form to request a physician appointment.
- I understand that follow-up emails from Dr. Lenoir NOW will not be on a secure server.
|