Non-HIPPA Contact Form

• Name:
• Email Address:
• Reason:
  • Appointment
  • Suggestion
  • Compliment
  • Complaint
  • Other
• Contact Phone:
• Message:
• :

• DISCLAIMER:This form is not HIPPA compliant. Please do not include sensitive medical or personal information. Login to Patient Portal at https://my.allergyclinicohio.com for Secure Patient Communication