IHG 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, however, unlike our other web forms this form is automatically emailed to our office staff and forwarded to your therapist. It is therefore less secure than using an online form that remains on the server and is essentially the same as emailing your therapist. Please do not include any information that you would not feel comfortable emailing to your therapist from your regular email account.

Patient Information

* Patient First Name

* Patient Last Name

* Date Of Birth

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

* Phone number where you can be reached

* Email Address

Message to your therapist

Please note, this form is to be used to send messages to your therapist (LCSW, PsyD, PhD) only. To send messages to your physician, physician assistant, or advanced practice nurse, you must use the link to RelayHealth from the IHG website.

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

Your message: (PLEASE NOTE! This method of communication is only for non-urgent communications with your therapist. Do NOT 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