ELECTRONIC FORM DISCLAIMER: Compass Medical is deeply committed to protecting our patient’s rights to privacy and safeguarding patient information. Please know we are working hard to bring our patients to secure electronic messaging in the near future, however, at this time, we do not offer secure messaging. Therefore, please do not attempt to fill out this form and send it back to Compass Medical electronically. Please bring the completed form with you to your next visit. If you attempt to send this form back via fax, email, or any other means, you expressly assume all risk of any unauthorized disclosure of your information.