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Patient Information
Copy data from family member
Enter family's login info
User ID:
Password:
Please fill in with alphabets.
Personal Information
*
*Required Information
Last Name (Family Name)
*
First Name
*
Gender
*
Date of Birth
*
Marital Status
*
SSN:
Address
*
Address 2
City
*
State
*
Zip/Postal Code
*
Country
*
Email
*
Phone
*
Cell Phone
Fax
Company Information
Company Name
Address
Address 2
City
State
Zip/Postal Code
Country
Phone
Ext
Fax
Insurrance Policy Holder
Same as Personal Information
Last Name
First Name
Gender
Date of Birth
Marital Status
SSN:
Address
Address 2
City
State
Zip/Postal Code
Country
Email
Phone
Fax
Relationship
Emergency Contact
Same as Personal Information
Last Name
*
First Name
*
Relationship
*
Address
*
Address 2
City
*
State
*
Zip/Postal Code
*
Country
Phone
*
Submit
Clinic
*
Security Question
*
Answer
Other
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.
*
I Agree
