PHS-Telehealth-Registration-Form

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Please enter the patient's information below to register

*If you wish to register your minor child for Online Visits, please complete a registration for yourself BEFORE adding minor children

First Name *This question is required.

Last Name *This question is required.

Date of Birth *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

Gender *This question is required.

Female	Male
Female	Male

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State Abbreviation *This question is required.

Zip *This question is required.

Email Address *This question is required. (Please enter parent or guardian email for minors) This question requires a valid email address.

Primary Phone *This question is required.

Alternate Phone (optional)

Work Phone (optional)

2. What type of visit would you prefer? *This question is required.