New User Setup
This information is to create a New User account and is different from establishing a New Patient record.
Personal Information
First Name:
*
Last Name:
*
Date of Birth:
*
(mm/dd/yyyy)
Address Information
Mailing Address:
*
City:
*
State:
*
Zip:
*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Contact Information
At least 1 phone number required
Home Phone:
Work Phone:
Cell Phone:
User Information
Email Address
(this will be your Username):
*
Password:
*
Confirm Password:
*
