UHA Medical Center

I understand and agree that any information submitted will be forwarded to our office by email and not via a secure messaging system. This form should not be used to transmit private health information, and we disclaim all warranties with respect to the privacy and confidentiality of any information submitted through this form.*

By checking this box, I consent to receive text messages related to SMS from UHA Medical Center. You can reply 'STOP' at any time to opt-out. Message and data rates may apply. Message frequency may vary; text HELP for assistance.