Indiana Health Group Online Patient Communication Form

www.indianahealthgroup.com

703 Pro-Med Lane

Carmel, IN 46032

317.843.9922 phone

317.581.3918 fax

400 Green Meadows Drive

Greenfield, IN 46140

317.462.8882 phone

317.462.9644 fax

Important Privacy Notice! This online form is hosted on a secure, encrypted server. When you leave a message, we receive a generic notification and then log on and check your message. In order to protect your privacy, your message is not sent to us in an unencrypted fashion.

* Patient First Name

* Patient Last Name

* Date Of Birth

Name of person sending this message (if different than the patient named above)

* Phone number

* Email Address

* Please select the person to whom you wish to send a message.

Your message: (PLEASE NOTE! This method of communication is only for non-urgent communications with your clinician. Do NOT attempt to use this form to schedule, change, or cancel an appointment without confirming it with our office staff in person or on the phone. Your message may not be seen for 1-2 business days).

* Indicates Response Required