Patient Registration

HAPPY HOLIDAYS! ENJOY GIFTING SOMEONE A FREE MEDICAL RECOMMENDATION FOR CHRISTMAS! TWO DOCTORS APPOINTMENTS FOR THE PRICE OF ONE: $49.99!

We are grateful to you as our valued patient. Let's get you registered! YOU CAN ALWAYS GO TO OUR WEBSITE TO LEARN MORE: JIFFYDOCTOR.COM
WHO WOULD YOU LIKE TO GIFT A MEDICAL CARD RECOMMENDATION TO? Please put N/A if your sign up is for you only. Thank you! If you have been gifted a doctor's visit, please fill out everything below.
Please send this form to them so we can get them on the calendar!

https://pci.jotform.com/form/253275470583159
What Legal State are You In?
Are you a Renewal Patient or a New Patient?

New PatientRenewal
Name*

First NameLast Name
Email
example@example.com
Address*

Street Address

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

YearMonthDay
Date
If Full Service, please upload your Driver's License here:

Cancelof
Where do you want your medical card mailed? If applicable...
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. 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.
Signature

Powered by Jotform SignClear

OPTIONS: YOUR CREDIT CARD STATEMENT WILL SAY NV CREATIVE ENTERPRISES, LLC WHICH IS OUR PROCESSOR.*

Jiffy Patient SpecialThank you for your loyalty! Full Service recommendation. We upload your information to the State.

$49.99

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

Should be Empty:

HAPPY HOLIDAYS! ENJOY GIFTING SOMEONE A FREE MEDICAL RECOMMENDATION FOR CHRISTMAS! TWO DOCTORS APPOINTMENTS FOR THE PRICE OF ONE: $49.99!

Please send this form to them so we can get them on the calendar!

Jiffy Doctor - Patient Registration