Notice for Patient Intake Form online users
- In here (Patient Intake Form), you will be able to upload your images.
- Each login session for the patient intake form will only allow you to access for 30 minutes.
If you would like to upload your images (self-scan) please follow the instructions
- Taking Your Face and/or Hand Pictures
- Please carefully read the instructions at Your at Home Care.
- Upload Your Pictures
- Click on a provided "Patient Intake Form" link showed below.
- Read the noticed of privacy practices and then enter the agreement code.
- Click "I Agree".
- Fill in all the required fields and password.
- Click "Returning Patient".
- Carefully make a page by page review and update of your patient intake form.
- The system will then provided you with an upload corresponding to your medical information.
PATIENT REGISTRATION FORM
is available at
You may click
to enter the
PATIENT REGISTRATION SITE