A clear approach
to privacy.

The form asks for your name, phone number, email, office, patient status, and preferred appointment date and time. It records your agreement to be contacted about the request.

Please do not submit medical details, insurance numbers, payment information or other sensitive records. Arrange to share those directly with the practice.

Requests are stored in the site’s database and can be reviewed by the authorized site administrator in a protected inbox. Access can be granted to authorized practice staff for scheduling.

Your contact information is used to follow up about the visit you request, not to enroll you in marketing. A request does not reserve a time or create a treatment plan.

The public website does not display submissions. Server validation and limited request frequency help reduce misuse; hashed phone and network identifiers are stored for abuse prevention.

Contact your chosen office about a correction, deletion, or the practice’s separate patient-record privacy notices.