New Portal Login Request

 

Thank you for requesting a new portal login. This request is to be filled out by the parent or legal guardian responsible for payment. Please use the parent or guarantor's name, address, phone, email, DOB and gender to complete this form (not the patient). Complete the form and click submit, and we will respond to your request in 1 business day. You will be sent a new user name and temporary password to gain access to the new portal. 

* Required Fields

Name
First *MiddleLast *
Address *
City *
State *
Zip *
Phone 1 *  Ext  Type 
Email Address *
Confirm Email Address *
DOB *
Sex *
 
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Anti-Spam Code *
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