Select Preferred LocationMilford, CTStamford, CT I accept the Terms and Conditions By checking the box on the contact form, you agree to the Terms of Use listed here: Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agree to hold Connecticut Skin Institute (the Practice), its doctors and affiliates, harmless from any hacking or any other unauthorized use of your personal information by outside parties. Your use of this form to contact the practice will result in an email being generated which will include all information you provide and delivered to Connecticut Skin Institute By checking the box on the form: You are accepting that Connecticut Skin Institute communicate with you via email at the address provided, in response to you submitting Connecticut Skin Institute’s Contact form. If you selected the “Phone” as your preferred way of being contacted, Connecticut Skin Institute will respond to your request via telephone. IF YOU DO NOT WANT TO USE EMAIL YOU MUST CONTACT CONNECTICUT SKIN INSTITUTE DIRECTLY BY TELEPHONE. You have reviewed the “Important Information About Email” notice provided below and understand the information contained within the notice. Despite the possibility that the email systems utilized may not be encrypted or secure and there are no assurances of confidentiality, you consent to the Practice communicating with you via email. You understand that you may withdraw this consent at any time by delivering written notice to Connecticut Skin Institute IMPORTANT INFORMATION ABOUT EMAIL THIS NOTICE DESCRIBES THE RISKS ASSOCIATED WITH UNENCRYPTED EMAIL. PLEASE REVIEW IT CAREFULLY. Security Risks Most standard email providers such as Gmail, Yahoo, Hotmail, etc. do not provide a secured or encrypted means of communication. As a result, there is risk that any protected health information contained in an email may be disclosed to, or intercepted by, unauthorized third parties. Additionally, email messages accessible through personal computers, laptops, or phones have inherent privacy risks especially when the email account is provided by an employer, when the account is not password protected, or the account is shared. Use of more secure communications, such as phone, fax or mail is preferred and always an available alternative. Responsibility When consenting to the use of email through such unsecured or unencrypted systems, you are accepting responsibility for any unauthorized access or disclosure to protected health information contained within the message. Connecticut Skin Institute will not be responsible for unauthorized access of protected health information while in transmission and will not be responsible for safeguarding information once it is delivered to you. Connecticut Skin Institute will take steps to ensure that any email with protected health information is protected prior to being sent to the requested address and will use the minimum necessary amount of protected health information when communicating with you. Additional Information It is important to understand that emails will not be used to replace or facilitate communications between you and your physician and will not be considered private communications. There is no guarantee that Connecticut Skin Institute will be actively monitoring the inbox so responses and replies sent to or received by you or Connecticut Skin Institute may be hours or days apart. Email messages may be inadvertently missed or errors in transmissions may occur. Connecticut Skin Institute will not be responsible for any issues caused by delays in communications. If you have an immediate need or an emergency situation, you must contact Connecticut Skin Institute by telephone or dial 9-1-1 if applicable. Connecticut Skin Institute's staff will be utilized to monitor the inbox in order to properly direct or respond to communications received. Therefore, any information considered sensitive should not be included in your communications. At Connecticut Skin Institute's discretion, any email message received or sent may become part of your medical record.
