REGISTRATION FORM

To be connected to a member of our team, please complete and submit a registration form:

Name*
Gender
Address
I am a*

The Partners HealthCare standard is to send email securely. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Partners HealthCare. If you prefer, we can send you "unencrypted" email that is not secure and could result in the unauthorized use or disclosure of your information. If you want to receive communications by unencrypted email despite these risks, Partners HealthCare will not be held responsible. Your preference to receive unencrypted email will apply to:

For research: Emails sent to you from research staff in this study. If you wish to communicate with other research staff at Partners regarding additional studies, your preference will have to be documented with each research group.

For clinicians: Emails sent from clinicians and staff at this practice or department.

Permission to email unencrypted messages?*