Please write your Date of Birth and Contact Phone number in the message for us to reach you. Disclaimer: If you have, or suspect you may have, an illness or condition that you believe requires medical attention, we recommend you call your primary care physician. If you believe you are experiencing a medical emergency please call 911 (or your local medical emergency number) or seek immediate care from the nearest hospital emergency room. This form should not be used to communicate any confidential personal or medical information (PHI), but should only be used for appointment requests and general questions.