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 *

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.