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

1. Preparation
   • A Digital Camera
2. Taking Your Face and/or Hand Pictures
   • Please carefully read the instructions at Your at Home Care.
3. 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 ANOTHER SITE.
You may click HERE. to enter the PATIENT REGISTRATION SITE