New User Registration

User Information

Personal Information
*Required Information
*Last Name:		*First Name:
*Gender:		* Date of Birth:
*Marital Status:		SSN:	(XXX-XX-XXXX)
*Address:	To avoid mail to be undeliverable, please fill in the complete address including the room number.
*City:		*State:
*Zip/Postal Code:		*Country:
*Email:
*Phone:		Fax:
Cell Phone:
Company Information
*Please fill in Company Name as some companies have their own exam plan package.
Company:
Address:
City:		State:
Zip/Postal Code:		Country:
Phone:	Ext.:	Fax:
Emergency Contact
*Fill with the contact info of the person other than the one being checked up
*Last Name :		*First Name:
Relationship:
*Phone:
*Clinic Location

Security Question:
Your answer to the security question.:

Authorization for Information Disclosure and Insurance Payment Process
I authorize to disclose my health information obtained by the diagnostics, treatments and as the result of examination to the insurance company. I authorize to process the claim to the insurance company and payment to be made directly to the clinic to cover the fee of medical treatment that I receive. I also agreed to pay any fee not covered by the insurance to the clinic or the doctor in the timely manner.
I AgreeI Do Not Agree