Northwest Diagnostic Clinic, PA

Thank you for using our website to communicate with your doctor. This form will assist us in processing your communication via your doctor's ASSISTANT, or one of her coworkers.

PLEASE UNDERSTAND THAT YOU ARE SUBMITTING THIS MESSAGE OVER THE INTERNET. DO NOT INCLUDE ANY SENSITIVE MEDICAL INFORMATION IN YOUR MESSAGE, FOR WE CANNOT GUARANTEE THAT IT WILL NOT BE SEEN BY OTHER PARTIES.

OUR ASSISTANTS CHECK THEIR E-MAIL PERIODICALLY DURING THE DAY, SO YOU MAY NOT RECEIVE AN IMMEDIATE RESPONSE FROM THEM, EITHER VIA TELEPHONE OR BY RETURN E-MAIL. WE APPRECIATE YOUR PATIENCE.

PLEASE DO NOT REQUEST A "SAME DAY APPOINTMENT" VIA THIS WEBSITE.

Should you have any questions, please contact your doctor's assistant via her telephone extension. Click here to see a listing of our telephone contact information.

Thanks!

This message is:

PLEASE NOTE: URGENT MESSAGES MAY NOT BE RETURNED THE SAME DAY. IF YOU HAVE AN URGENT NEED TO CONTACT US, DO NOT USE THIS FORM

Please help us identify you:

First Name

Last Name

Date of Birth (mm/dd/yy) REQUIRED FOR IDENTIFICATION
Daytime Telephone (between 8 a.m. and 5 p.m.)

If you would like us to respond via e-mail, what is your e-mail address?

(by providing an e-mail address, you give us permission to respond to you via e-mail, such response to include any information you provide us via this form)

PLEASE PROVIDE US WITH EITHER A DAYTIME TELEPHONE
NUMBER OR AN E-MAIL ADDRESS. DO NOT LEAVE BLANK.

Pharmacy name and number:

Who is your regular doctor?

Where is your chart kept?

What is your question? (please limit your response to the space below)

First Name
Last Name
Date of Birth	(mm/dd/yy) REQUIRED FOR IDENTIFICATION

Northwest Diagnostic Clinic, PA

Constructed by John Watson [7/5/2001].Copyright © 2001 [Northwest Diagnostic Clinic, PA]. All rights reserved. Revised: January 07, 2011

Constructed by John Watson [7/5/2001].
Copyright © 2001 [Northwest Diagnostic Clinic, PA]. All rights reserved.
Revised: January 07, 2011