Your Information

First Name:

Last Name:

Email Address:

Daytime Phone:

What are your concerns?

By checking this box you agree to the Terms listed here:
This new patient form is encrypted, HIPAA-compliant and secure. However, due to the nature of the Internet, use of email and other website features outside this patient portal cannot be guaranteed as 100% secure. By checking this box, you hereby acknowledge this and agree to hold harmless Dr. Scheiner and his office, doctors and affiliates from unauthorized use beyond their control of any personal information submitted outside this patient portal application.