Register with Demo Practice

DO NOT ENTER PERSONAL INFORMATION IN THIS FORM. This registration form is part of a publicly-available DEMO Patient Portal, and is not connected to any healthcare clinic. If you have reached this page looking to register as a new patient with a specific clinic, please inquire with that clinic directly.

Basic Contact Information

Date of Birth *

Your Address

Contact Information

Emergency Contact

Insurance Information

Note: Our practice does not bill insurance, but this information makes it easier for us to refer you for other services (like labs or specialists)

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the patient portal in the future.

Your username must be at least 4 characters long

Your password must be at least 8 characters long and include at least one number or special character.

The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.

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