Step 3: Patient Information

Please provide your information to complete your appointment booking

Personal Information

First Name *

Last Name *

Email Address *

We'll send appointment confirmations and reminders to this email

Phone Number *

Create Password *

Must be at least 8 characters long

Confirm Password *

Re-enter your password to confirm

Date of Birth *

Health Information

What are your primary health concerns? *

This helps your doctor prepare for your visit

Known Allergies (optional)

Enter any known allergies. Leave blank if none.

Privacy & Data Security

Your information is protected by HIPAA and our strict privacy policies. We use industry-standard encryption to secure your data and will never share your personal information without your consent.

Terms and Consent Agreement

I agree to the Terms of Service, Privacy Policy, Medical Services Consent, Telehealth Consent, and Marketing Consent. I consent to receive appointment reminders and healthcare communications. *

SMS Communication Consent

I agree to receive SMS text messages for appointment reminders and patient communication. These messages will not be used for marketing purposes and are solely for healthcare-related communications. Standard message and data rates may apply. *