Health and Resource Center Registration

First Name * Middle Initial
Last Name * Suffix
Address 1 *
Address 2
City * State *
Zip *

>You must enter at least one of the following contact
methods for the patient.
Primary Phone
Secondary Phone
Email Address

Emergency Contact Name *
Emergency Contact Phone *

Last 4 digits of SSN *
Date of Birth *
Employment Status *
Employer
Primary Care Provider *
If you do not have a current primary care physician, please enter "None"

Package Plan *
Price  
 
Description  
 

Payment is required in advance of your first appointment.

A scheduling consultant will contact you to assist with making your first appointment.

If you choose to not to make a credit card payment now, please be prepared to make your payment at that time.

Card Type
Name on Card
Card Number
Expiration Date