Patient Portal Access Request
Please fill out the information below to request an invitation to the Health and Wellness Center's Patient Portal. Upon submission of this form, you will receive an e-mail within 1-3 business days that will provide instructions for completing your registration.

Patients MUST successfully complete the registration process AND login to the Patient Portal between December 13th and December 31st to be entered in a drawing to win a $100 Visa Gift Card.

Email address *
First Name *
Your answer
Last Name *
Your answer
Birthdate *
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DD
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I am the... *
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