Informed-Consent-1

May 25, 2018 by Kelly Shores Leave a Comment

Informed-Consent-1

314 Elm Street
Fortville, IN 46040

317-207-9333
info@restorationcounselingindy.com

Send a Message

Name *

E-mail *

Phone

Comment or Message

Terms of Use *

Yes, I want to submit this form

By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Brighter Vision harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Website

Privacy Policy

A Bright Site by Brighter Vision