The appointment request form requires you to answer confidential health information that is needed to complete your request and shall be utilized only for the purpose of helping you secure an office visit. Your information will be transmitted by e-mail and will not be secured by encryption software. It is possible that this information could be intercepted by non-authorized individuals engaging in illegal internet monitoring activity. By reading the Confidentiality Notice and providing the required health information, you consent to disclose confidential health information to a Northwestern Memorial affiliated physician. You also acknowledge the risk of sending your information via e-mail and agree to not hold Northwestern Memorial or any of its affiliates, employees or agents liable for any damages you may incur as a result of the transmittal of your information.