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Create Patient Account

Create an account to manage your medical record requests

Personal Information

First Name*

Last Name*

Email Address*

We'll use this email to send you updates about your medical record requests

Account Security

Password*

Must be at least 8 characters long

Confirm Password*

Re-enter your password to confirm

Date of Birth*

Enter your birth date for identity verification

Phone Number*

10-digit phone number for account notifications

Address*

Complete mailing address for medical record delivery

By creating an account, you agree to our Terms of Service and Privacy Policy. Your information will be used solely for managing medical record requests and is protected under HIPAA regulations.

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