New User Registration

User Information

Copy address, Email, Phone, Fax, Cell Phone information of already registered family member.
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:
*Phone: Fax:
Cell Phone:  
Company Information
*Please fill in Company Name as some companies have their own exam plan package.
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:
*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.

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