Patient Portal Registration:
Form 3

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.
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.
*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.
no dashes
no dashes
*for doctors notes
Pharmacy Can Be of Preference OR For Patients Who Use Specific Pharmacy. (Ex: RiteAid. Tisdale Rd. 74996.) NO Pharmacy? Input N/A or None.
no dashes
*Enter address if emergency contact not in same home
Are you experiencing symptoms right now
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.