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***

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Please upload an image of your id or enter your drivers license number.
* Please take a photo of your id card and upload.
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Primary Insurance
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Please take a photo of the front of your insurance card and upload.
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Please take a photo of the back of your insurance card and upload.
Secondary Insurance
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Please take a photo of the front of your insurance card and upload.
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Please take a photo of the back of your insurance card and upload.
Tertiary Insurance
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Please take a photo of the front of your insurance card and upload.
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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.