New Patient Registration
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Personal Info
Contact Info
Insurance Info
Security Info
Sign-In Info
Last Name
*
First Name
*
Middle Name
DOB (MM/dd/yyyy)
*
Race
*
Ethnicity
*
Select Gender
*
:
Male
Female
Address1
*
Address2
State
*
City
Home Phone
Work Phone
Cell Phone
*
Email ID
*
Zip
*
Insurance Name
*
None
Insurance ID
*
Primary card holder first name
*
Primary card holder last name
*
Valid From
*
Valid To
*
Relationship to the primary card holder
*
None
Self
Spouse
Child
Self Pay
answer 1
answer 2
answer 3
Principal Doctor
*
Referring Doctor
Pharmacy Name
Username
*
Password
*
Confirm Password
*
eRx History Consent
Patient consents to receive the medication history from any prescriber
No consent given
Patient consents to receive the history of medications prescribed by this provider only
Parent/Guardian consents to receive the medication history from any prescriber
Parent/Guardian consents to receive the history of medications prescribed by this provider only
Current Medication list/Dose frequency
Password Strength:
Note:
1.
Password must have atleast 6 characters and must contain atleast one lowercase, one uppercase and one number.
2.
Click here to login, if you already have an account.
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