Patient Portal Form


In order to better serve our patients, we are now offering access to a secure patient portal from which you will have access to your records, prescriptions, and other information online. Please provide an email address to begin this process.

We will use this email address for the patient portal, appointment reminder, office closure notices, and notifications of office events such as our manual Trunk Show.

Your email will remain securely within our office records for the above purposes and will not be given to third parties. If you provide your email address, you will receive access to the portal via an email. If you do not provide an email address, a username and password will be generated and available to you within the next two business days. Once you have logged in to the portal, please send us a message from within the portal letting us know you were able to view your record.

Signature of Patient


Patient Email Address

*Secure messaging portal utilizes HIPAA-approved data encryption and SSL support which ensures security and is password protected.