Patient portal registration form

Health365 Patient Portal Form

Fill out the form carefully for registration to receive a username and password via email. Don't forget to attach a form of photo ID. Please activate your account within 24 hours of receiving the confirmation email, or the link will expire.
Patient Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
Gender
Personal E-mail*
example@example.com
Personal Mobile Number*
If applicable: Children under age 16 that you request access for:
Photo ID upload - Driver's license, passport, gun license*

Cancelof
Signature*

Clear
Should be Empty:

Health365 Patient Portal Form