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 paymentPlease 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

First *MiddleLast *
Address *
City *
State *
Zip *
Phone 1 *  Ext  Type 
Email Address *
Confirm Email Address *
Sex *
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