New User Registration

User Information

Copy address, Email, Phone, Fax, Cell Phone information of already registered family member.
Personal Information
*Required Information
*Last Name: *First Name:
*Gender: * Date of Birth:  (MM/DD/YYYY)
*Marital Status: SSN: (XXX-XX-XXXX)
*Address:
 
*City: *State:
*Zip/Postal Code: *Country:
*Email:    
*Phone: Fax:
Cell Phone:  
Company Information
Company:  
Address:
City: State:
Zip/Postal Code: Country:
Phone:   Ext.: Fax:
Insurrance Policy Holder
Same as Personal Information
Last Name: First Name:
Gender: Date of Birth: (MM/DD/YYYY)
Marital Status: SSN: (XXX-XX-XXXX)
Address:
City: State:
Zip/Postal Code: Country:
Email:    
Phone: Fax:
Relationship:
Emergency Contact
Same as Personal Information
*Last Name : *First Name:
Relationship:
*Address:
*City: State:
*Postal Code: Country:
*Phone:    
*Clinic Location
Other:
Security Question:
Your answer to the security question.:
 
Authorization for Information Disclosure and Insurance Payment Process
I authorize to disclose my health information obtained by the diagnostics, treatments and as the result of examination to the insurance company. I authorize to process the claim to the insurance company and payment to be made directly to the clinic to cover the fee of medical treatment that I receive. I also agreed to pay any fee not covered by the insurance to the clinic or the doctor in the timely manner.