Contact Us Form

If same as legal name, please put legal name

With area code

address, apt/unit, city

If you are from outside the USA, please select "NONE"

If from outside the USA, please put "46202" and comment your correct address at the end of the form

if you do not have one, please say "NONE"

If you do not have one, please put "NONE"

If you are not on HRT, please leave this field blank

If you do not have a primary doctor, please say "No"

in inches - please calculate online before sending

in lbs.

Month-Day-Year

Month-Day-Year

If "Other," please clarify at end of form

If none of these options describe how we can contact you, please detail your needs at the end of the form

This is to maintain your confidentiality should you allow us to leave a message

If you do not have this now, please contact your insurance Customer Service and request a copy. Sending it will assist us in completing your benefits check in a more timely manner!

E-mail may be used to communicate about scheduling, surgery, insurance and billing information. I understand email is a substitute for other forms of communication and that email should never be used for emergency situations or urgent problems. In the event of an emergency, I will call 911 or go to an emergency room, urgent care, or immediate care facility. Risks include circulating email, email broadcast, human error, falsification of information, backed-up or archived copies after a message is deleted, interception and transfer of information, viruses, and emails as legal documents in a court of law. IU Health takes the following precautions to protect your protected health information: identifiable information is never forwarded to a third party except for treatment, payment, or healthcare operations purposes without your express permission, patient emails are never given for marketing purposes, professional emails are not shared with patient's family members, emails are backed up and archived regularly, and patient email addresses are verified prior to sending the message with a confidential indicator attached for the recipient. By signing, I agree to indemnify and hold harmless the provider, his or her medical practice, IU Health Physicians, and its trustees, officers, directors, associates, agents, information providers, suppliers, and website designers and maintainers from and against all losses, expenses, damages and costs, including reasonable attorney fees, relating to or arising from any information loss due to technical failure, my use of the internet to communicate with the provider, the use of the provider's website, any arrangements I make based on the information obtained at the site, any products or services obtained at the site, and any breach by me of these restrictions and conditions. The provider does not warrant that the functions contained in any materials provided will be uninterrupted or error-free, that defects will be corrected, or that the provider's website or server that makes such site available is free of viruses or other harmful components. I understand there may be times in which the provider must forward the information I have provided via email to a third party for billing, treatment, or payment purposes. I expressly provide my consent by signing below for the provider to forward these emails to a third party under these conditions and evidence my consent by signing below. I have the right to revoke this consent, in writing, at any time by presenting the written revocation to my healthcare provider. The provider shall have the right to immediately terminate the email relationship with me if he or she determines, in her or her sole discretion, that I have violated the terms and conditions set forth in the Agreement or have engaged in conduct which the provider determines to be unacceptable. By typing my full name below, I hereby consent to the use of emails as a means of communication between an IU Health Physicians provider, his or her office staff, and myself. I understand the inherent limitations related to electronic communications, understand the limits of email transactions, hold harmless IU Health Physicians for loss of information due to technical failures and consent to these conditions and terms.