Patient Portal Registration:Form 3 Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastState *- Select Here -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto RicoUS Virgin IslandsOtherIf other, input country, province, state or territory *Do You Have A Photo ID and/or Insurance Card? *Photo IDInsurance CardNone or Bypass UploadBothNote : 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 IDInsurance CardNone or Bypass UploadBothNote : 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?YesNo*for patients using Insurance for PrescriptionsAddress *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip 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) *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex *MFHome Phone #Cell Phone # *no dashesPatient's Social Security # (SSN) *no dashesEmployer or School*for doctors notesPharmacy *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 *YNEmergency Contact Name *FirstLastEmergency Contact # *no dashesEmergency Contact AddressAddress Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip Code*Enter address if emergency contact not in same homeEmergency Contact SSN ** last 4 if patient under 18Emergency Contact Relationship *- Select Here -SpouseFatherMotherSon/DaughterGrandmotherGrandfatherLegal GuardianOthersAre You Using Insurance For Prescriptions? *YesNoPrimary Insurance Company Name *- Select Here -Self-PayAetnaBlueCross/BlueShieldTri-CareCignaHumanaMedicaidMedicareVAOtherFor Prescription Insurance OnlySecondary Insurance Company Name- Select Here -Self-PayAetnaBlueCross/BlueShieldTri-CareCignaHumanaMedicaidMedicareVAOtherFor Prescription Insurance OnlyInsurance Company Name: (if not listed)Primary Insurance Policy # *Secondary Insurance Policy #Relationship to Insured *- Select Here -SelfSpouseChildEmployeeLife PartnerOther/UnknownPrimary Policy Holder Name *FirstLastPrimary Policy Holder SSN *Last 4 if matches aboveDo You Have Email Confirmed Appointment Date and Time? *YesNoEmail *Are You Symptomatic? *YesNoAre you experiencing symptoms right nowFamily 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.PhoneSubmit Back to Profile