New User Registration

User Information

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

Security Question: Required
Your answer to the security question.: Required

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