Patient Pre-Registration

Register

Demographics

***Please ensure that the patient name and date of birth are identical to the information appearing on the patient's government issued ID***

Patient Last Name

Patient First Name

Middle Initial

Patient Date of Birth

Patient Street Address

Patient Address Line 2

Patient City

Patient State / Province

Patient Zip Code

Patient Email address

Patient mobile number

Sex (at birth)

Race

Ethnicity

Please upload an image of your id or enter your drivers license number.

Id Card (Parent/Guardian ID for patients under 18) Please take a photo of your id card and upload.

Drivers license number

Primary Insurance

Insurance Provider

Member ID

Group Number (Optional)

Medical Insurance Card - FRONT

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK

Please take a photo of the back of your insurance card and upload.

Secondary Insurance

Insurance Provider

Member ID

Group Number (Optional)

Medical Insurance Card - FRONT

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK

Please take a photo of the back of your insurance card and upload.

Tertiary Insurance

Insurance Provider

Member ID

Group Number (Optional)

Medical Insurance Card - FRONT

Please take a photo of the front of your insurance card and upload.

Medical Insurance Card - BACK

Please take a photo of the back of your insurance card and upload.

*By clicking submit the patient gives authorization for test results and associated protected health information (PHI) to be sent via digital delivery methods including SMS text and email.