Jiffy Doctor - FINAL AND CORRECT Patient Registration

JIFFY PATIENTS

Welcome to Jiffy Doctor! We are grateful to you as our valued patient. Let's get you registered!
Name*

First NameLast Name
Email
example@example.com
What is the OMMA Password you used to create your account?
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.
Date

YearMonthDay
Date
PLEASE upload your Driver's License here:

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If you answered yes to being a disabled veteran, please upload proof of your disability.

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If Full Service, please upload your insurance card here:

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Where do you want your medical card mailed, IF APPLICABLE?
Please upload the front and back copy of your payment method for Jiffy Doctor to pay your State Fees (IF APPLICABLE) unless you are going to pay it yourself.

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Jiffy Doctor - Patient Registration

THE TIME YOU CHOOSE IS NOT YOUR DOCTOR'S APPOINTMENT TIME. IT IS FOR OUR PROVIDER TO REVIEW YOUR INFORMATION. IT IS NOT YOUR DESIGNATED PHONE CALL TIME. WE WILL CALL YOU THE SAME DAY OF YOUR APPOINTMENT. OUR CUT OFF TIME IS 4:00 P.M. IF YOU REGISTER AFTER 4 P.M., YOU WILL BE CALLED THE FOLLOWING DAY. PLEASE ADD 405-655-8028 TO YOUR CONTACTS. IF YOU MISS YOUR APPOINTMENT AFTER THE THIRD TRY, THERE ARE NO REFUNDS. YOU WILL HAVE A PAYMENT LINK IN YOUR CONFIRMATION EMAIL. PLEASE DO NOT CHOOSE MORE THAN ONE SERVICE OR SIGN UP MORE THAN ONCE. WE CAN NOT REFUND YOU IF YOU DO SO. THANK YOU! YOUR CREDIT CARD STATEMENT WILL SAY NV CREATIVE ENTERPRISES, LLC WHICH IS OUR PROCESSOR.
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OPTIONS: YOUR CREDIT CARD STATEMENT WILL SAY NV CREATIVE ENTERPRISES, LLC WHICH IS OUR PROCESSOR.*

Jiffy Patient Special

FOR BOTH NEW PATIENTS AND RENEWALS. Full Service recommendation. We upload your information to the State IF APPLICABLE.

$49.99

New Patient-OKLAHOMA ONLY

Full Service recommendation. We upload your information to the State.

$100.00

Renewal Patient-OKLAHOMA ONLY

For Patients who need a renewal. We upload your information to the State.

$75.00

Enter coupon

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

MOST STATES NOW REQUIRES YOUR SOCIAL SECURITY NUMBER. PLEASE ENTER IT HERE OR WE CAN NOT PROCESS YOU. YOUR FORM IS ENCRYPTED AND HIPAA COMPLIANT.
Should be Empty:

JIFFY PATIENTS

Jiffy Doctor - Patient Registration