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User Self-Registration

After successful completion of this form you will receive a confirmation email. Only after confirming receipt of the email will your eTools account be active.

Special instructions:

  • Confirmation codes are case sensitive and must be entered exactly as it appears in your statement.
  • A birth date for any patient on the account is required for verification purposes.
  • All fields are required.

First Name:
Last Name:
Account Number: Format: 12345601234
Patient Birth Date:  /  / 
Month       Day         Year
Confirmation Code:
Email: (This will be your username.)
Confirm Email:
Password:
Confirm Password:

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