Name *

First Name

Last Name

Date of Birth

MM

DD

YYYY

Phone

(###)

###

####

Is it okay to leave you a message at this number?

Yes

No

The information in this form goes to Richard Walters’s unencrypted email account. Mr. Walters applies reasonable safeguards to protect health information sent electronically. However, Mr. Walters cannot guarantee the security and confidentiality of email communication. Please check this box, acknowledging that you understand the risks of email communication. *

Check the box to confirm