I acknowledge that the information I am submitting may include protected health information ("PHI") as defined under the Health Insurance Portability and Accountability Act ("HIPAA"). I understand that this information will be transmitted electronically to the healthcare practice I have selected. By checking this box, I consent to the electronic submission and transmission of my information for the purpose of requesting an appointment or related services. Further, you represent that you have the authority to make this acknowledgement, either as the individual for whom this form is intended or as the personal representative of such user. I understand that while this form uses encryption to protect my information during transmission, no electronic communication can be guaranteed to be fully secure. For more information about Dr. Troy Gombert's privacy policy, please see
our privacy policy.