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Photo Upload Form
Please upload a clear photo of Drivers License and Insurance Card
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HIPAA
Compliance
1
Patient's Name
*
This field is required.
First Name
Last Name
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2
E-mail
*
This field is required.
Please use a valid email address
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3
Is the patient a minor (under 18 years old)?
YES
NO
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4
Upload Photo of Parent/Guardian Drivers License
*
This field is required.
Only the following file format is accepted jpg,jpeg, & png.
Drag and drop files here
Select files to upload
Upload a File
Front & Back
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of
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5
Upload Photo of Drivers License
*
This field is required.
Only the following file format is accepted jpg,jpeg, & png.
Drag and drop files here
Select files to upload
Upload a File
Front & Back
Cancel
of
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6
Upload Photo of Insurance Card
*
This field is required.
Only the following file format is accepted jpg,jpeg, & png.
Drag and drop files here
Select files to upload
Upload a File
Front & Back
Cancel
of
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Enter
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