Insurance Card & Photo ID Capture
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Email Address (or parent/guardian email if a minor)
*
example@example.com
Photo Upload - FRONT of your insurance card and photo id (include both in your image):
*
Photo Upload - BACK of your insurance card (not necessary for photo id):
*
Patient Signature (or parent/guardian signature if a minor)
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: