The secure way to communicate with your Doctor

Disclaimer: it's a long story, but while Twistle is HIPAA-compliant, this form is not.  Information submitted on this form is used to send you an invitation to the Twistle application.  While we make every attempt to protect your privacy, we need to inform you that this form does not meet the inordinately complex requirements of HIPAA.  By submitting this form, you authorize the transmission of this information to us.  Alternatively, you can provide us this information, in person, when we see you in the office.

Name *
Date of birth *
Date of birth
Are you a direct care member? *
Mobile/cell phone number
Mobile/cell phone number
When sending you the invitation to connect, where would you prefer we send it? *