Frontline MDs Portal Registration

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Patient Portal Registration:
Form 2

Name *

First

Middle

Last

State *

If other, input country, province, state or territory *

Do You Have A Photo ID and/or Insurance Card? *

Photo ID
Insurance Card
None
Both

Note : UPLOAD ISSUES? SKIP UPLOAD BY SELECTING NONE. Photo ID meaning a Drivers License or State ID card and Insurance Card is for Prescription Coverage Only.

Upload Photo ID AND/OR Insurance Card HERE *

Click or drag files to this area to upload. You can upload up to 4 files.

Save Time. Upload Photo ID (Drivers License or State ID) and Insurance (For Prescription Coverage Only).

Did You Upload:

Photo ID
Insurance Card
None
Both

Note : UPLOAD ISSUES? SKIP UPLOAD BY SELECTING NONE. Photo ID meaning a Drivers License or State ID card and Insurance Card is for Prescription Coverage Only.

Driver's License or State ID # *

Does The Address On Your Photo ID Match The Address The Insurance is Under?

Yes
No

*for patients using Insurance for Prescriptions

Address *

Address Line 1

Address Line 2

City

State

Zip Code

*Enter Address Line 2: If Photo ID (Drivers License or State ID) has wrong address or you have alternate address than on Photo ID; or if address on Photo ID is not same as address prescription insurance is under.

Confirm Patient's Date of Birth (DOB) *//

Sex *

M
F

Home Phone #

Cell Phone # *

no dashes

Patient's Social Security # (SSN) *

no dashes

Employer or School

*for doctors notes

Pharmacy *

Pharmacy Can Be of Preference OR For Patients Who Use Specific Pharmacy. (Ex: RiteAid. Tisdale Rd. 74996.) NO Pharmacy? Input N/A or None.

Is patient UNDER 18? If YES, enter Parent or Guardian info under Emergency Contact *

Y
N

Emergency Contact Name *

First

Last

Emergency Contact # *

no dashes

Emergency Contact Address

Address Line 1

Address Line 2

City

State

Zip Code

*Enter address if emergency contact not in same home

Emergency Contact SSN *

* last 4 if patient under 18

Emergency Contact Relationship *

Are You Using Insurance For Prescriptions? *

Yes
No

Primary Insurance Company Name *

For Prescription Insurance Only

Secondary Insurance Company Name

For Prescription Insurance Only

Insurance Company Name: (if not listed)

Primary Insurance Policy # *

Secondary Insurance Policy #

Relationship to Insured *

Primary Policy Holder Name *

First

Last

Primary Policy Holder SSN *

Last 4 if matches above

Email *

Are You Symptomatic? *

Yes
No

What kind of Treatment Plan are you looking for:

Single Visit (One-Time Treatment Plan)
Follow-Up Treatment Plan

Comments, Messages or Updates for Frontline MDs

Family Account: If you are a guardian for children under 18 list their Name. DOB and SSN in box. Family over 18? No need to create new account. Just make sure each has filled forms 1, 2, & 3 in Family Account profile.

Name

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Patient Portal Registration:Form 2

Patient Portal Registration:
Form 2