Patient Portal Contact Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

To sign up for the new WindberCare Patient Portal or get assistance with an existing account, please fill out the form below and we will assist you during regular business hours (M-F 7a-3p).

First and Last Name of Patient *

Date of Birth *

YYYY

Last 4 Digits of Social Security Number *

Email *

Phone Number *

I need help with: *

Setting up a new Patient Portal account

Resetting my password

Resetting my username

Other (specify in comments below)

Required

Comments

I certify that I am at least 18 years of age.

(Records for patients under 18 can be requested from our Health Information Management department by calling 814-467-3805.)

Yes

I certify that the above information is for: *

Myself

A patient for whom I have Medical Power of Attorney

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of windbercare.online.

Does this form look suspicious? Report

Forms