Patient Portal Access Request
Please use this form to request online access to our Patient Portal. We are working hard to process these requests as fast as possible and thank you for your patience.
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Parent / Legal Guardian Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Primary Office
*
Camillus
Liverpool
Activation Code
The Patient Portal sign up process requires an activation code. Once our team processes your request, you'll receive the activation code with instructions on how to activate your Patient Portal account.
How would you prefer to receive the activation code?
*
Pick it up in the office
Receive it via phone call
Receive it via fax
Fax Number
*
Fax Number
Who should receive the Fax?
*
Attn:
Please verify that you are human
*
Submit
Should be Empty: