Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Patient Portal Registration Form
Patient Full Name *
Date of Birth
____ / ____ / ________
Email for Portal Access
Mobile Phone Number
Preferred Username
Identity Verification (Last 4 SSN)
Communication Preferences
- Text message
- Phone call
Appointment Reminder Method
- Text message
- Phone call
Information acknowledgment
I confirm that the information I have provided is accurate to the best of my knowledge. I can contact the practice to correct or update it.
Signature
Date
Home Address
Patient Portal Registration Form template from formisoft.com. formisoft.com/intake-templates/patient-portal-registration