I give permission for JEFF NOW to use the information I supply on this form to
fulfill my request for a physician appointment and to contact me by email
if necessary using the email address I supply on the form.
I certify that I am at least 18 years old and I acknowledge that
I have read and accept these terms and agree to use this form to
request a physician appointment.
I understand that follow-up emails from JEFF NOW will not be on a secure server.