Patient Registration Form

Welcome to our online registration form for our scheduled patients. Rest assured that all information given is handled with confidentiality and will only be used for filing and convenience of operations purposes. Thank you!

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CLINIC AND HOME HEALTH SERVICES


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HMO

We value your privacy and are committed to protecting your personal information. By submitting this form, you consent to the collection, use, and disclosure of your personal data in accordance with our Privacy Policy. Your information will be used solely for the purpose of providing and managing your healthcare services and will only be shared with your HMO providers as necessary.


I agree to the Data Privacy Act and consent to the collection and use of my personal data as described above.