Frontline MDs Portal Registration

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Patient Portal Registration:
Form 3

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 or Bypass Upload
Both

Note : UPLOAD ISSUES? USING DESKTOP or LAPTOP? 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 or Bypass Upload
Both

Note : UPLOAD ISSUES? USING DESKTOP OR LAPTOP?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

Do You Have Email Confirmed Appointment Date and Time? *

Yes
No

Email *

Are You Symptomatic? *

Yes
No

Are you experiencing symptoms right now

Family Account With Minors?

Family Account: If you are a guardian for multiple children under 18 list their Name, DOB and Last 4 of SSN in box. Family over 18? No need to create new account. Just make sure each has filled forms 1, 2, & 3 under Additonal Family member in profile.

Phone

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Patient Portal Registration:Form 3

Patient Portal Registration:
Form 3