Name *

First Name

Last Name

Phone *

(###)

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I understand that communications via email over the internet are not secure. Although it is unlikely, there is a possibility that information I include in an email can be intercepted and read by other parties besides the person to whom it is addressed. I also understand that Rosana Lamontagne will coordinate our initial phone consult after I've scheduled it through the patient portal. I give her permission to leave me a message at the phone number and email address provided. *

I consent