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If you would like to hear back from us, please share your contact information, otherwise feel free to be anonymous. Please note there is a possibility that information you include on this form can be intercepted and read by other parties besides NorthLakes staff. Please do not include personal identifying information such as your birth date or specific medical conditions. If necessary or requested, a staff member will follow-up with you to get additional information. This form is not intended to be used for communication with providers. Please use MyChart or call the clinic to speak with someone regarding specific health care questions.