Indiana Health Group Online Patient Communication Form

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:
(MM/DD/YYYY)

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

* Today's Date
(MM/DD/YYYY)

Phone number

* Email Address

* Message Type:

Check this box if you would like to receive a copy of your message for confirmation:

Send me a copy

* Please select the clinician to whom you wish to send a message:

Dear Patient,
While you are always welcome to schedule or change your appointments in person at the office or by phone, using this online form to reschedule or cancel your appointment will create a "receipt" of your appointment change and guarantee that you will not be charged for a missed or late-canceled appointment as long as you cancel your appointment with at least one business day's notice.

Dear Patient, Please enter the refill information below including the name of the medication, strength, directions, number of pills in the bottle, and the name and telephone number of the pharmacy to which the medications should be sent.

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).

Need to upload a file? Use the button below. (max file size = 50MB)

* Indicates Response Required