ELKO Patient ID and Insurance Card
After submitting your Photo ID and Insurance (if applicable), you will be directed to our full registration form.
Name
*
First Name
Last Name
Take a picture your Driver License OR a State ID
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOT IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
What type of payment will you be providing today?
*
Please Select
Cash / Credit Card
Membership ($10 Visit)
Insurance
Take a picture the FRONT of your Insurance Card
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOT IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
Take a picture the BACK of your Insurance Card
Browse Files
Drag and drop files here
Choose a file
PLEASE MAKE SURE THE PHOT IS CLEAR BEFORE SUBMITTING (otherwise we cannot read). You can retake multiple times before submitting.
Cancel
of
Back
Next
Next Step -> Fill out ONLY Section 1 and 2, and then SKIP to Section 6 to sign off to finish.
After you are done, please contact the clinic
Submit and go to registration
Should be Empty: