Form Request for Electronic Communication

Please right-click this link to download the form as a fillable PDF.  You may fill it out on your device and email it to Marci at the email address shown on the form.

Alternatively, you may fill out the online version, below. Upon submission, you’ll see a message within a green box that says, “thank you, your message has been sent”, directly beneath the “submit” button. If you don’t see it, please scroll down.

    Clarity Consults LLC
    PO Box 841 • Pleasant Hill, OR 97455
    Phone: 541.915.5715 • Fax 541.343.7700

    codyclarityconsults@gmail.com

    Request for Electronic Communication

    I request that the following communication from Clarity Consults LLC. be delivered to me by the provided electronic means. I understand that this form of communication may not be secure, creating a risk of improper disclosure to unauthorized individuals. I am willing to accept that risk, and understand that the practice is not responsible if such an incident should occur.

    Communication:

    Methods:

    Please prove you're a human by answering this Math Captcha 🙂 16 + = 22