Patient Portal Registration Request

Patient Portal Registration Request

Please fill out the following and we will send your Patient Portal Registration link via email.
The patient for whom I am requesting portal access has either already been seen at AAICA or has an appointment scheduled.

YesNo
Thank you for being proactive! Our scheduling team is diligently working through our referrals. They will get you set up with access to your patient portal at scheduling.

Until you've been scheduled, we cannot set you up with a patient portal.

If you do not have a referral, please reach out to your primary care provider. We accept patients by referral only, and require all patients to be established with a primary care provider.
Patient's Full Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Email Address for Portal Link*
example@example.com
Will other patients use this same email address? (e.g. Other children within a family.)*

YesNo
If multiple patients will share the email address above, please let us know who to designate as the "parent account."

For example:
1. If Mom is a patient, then the children would be sub/alternate accounts of Mom's email address.
2. If multiple children are patients, but the parent is not, designate the oldest child as the primary account.
Parent Account Full Name*

First NameLast Name
Parent Account Date of Birth*

MonthDayYear
Date
Best Call Back Number in case we have questions.*
Please enter a valid phone number.

By clicking "Next," I understand that I will not receive a phone call unless there is a problem sending my portal link.

By clicking "Next," I understand that my Portal Link will come from ModuleMD and not AAICA.

By clicking "Next," I understand that I need to check my SPAM/Junk folder for the Portal Registration Email prior to submitting a second request.

By clicking "Submit," I agree to wait 48 business hours before sending a second request for portal access.

If I need to follow-up, I will do so via an email to Solutions@AllergyAlaska.com.
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