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Step 1. Create Billing Contact
Step 2. Activate Account
Step 3. Account Activated

Contact Information       Note: Red text indicates required fields.
Billing First Name:
 Billing Last Name:
Address 1:
Address 2:
Country:
  
Prov/State:
  
City: 
  
Postal/Zip Code: 
  
Phone 1: 
  
Phone 2: 
  
Fax: 
  
Email: 
  
Alternate Email:
   
Client #: 
  
 
Account Information
Username:
* We suggest your email address (Min Characters: 5)
Password:
Re-Type Password:  

Password Strength
     

Note: For the best Password Strength rating include:
  • Uppercase and lowercase characters
  • Numbers
  • Symbols
  • Eight or more characters
Extra Information
Sex At Birth:
  Male     Female     X     Decline to Answer  
Birthdate:
      
Guardian 1 Name:
 
Guardian 1 Phone:
 
Guardian 2 Name:
 
Guardian 2 Phone:
 
Emerg. Contact:
 
Emerg. #:
 
 Permission To Take Photo(s) Granted
Medical Information
Family Doctor:
 
Dr. Phone:
 
List any medication presently taken:

Do you have any of the following conditions or requirements?:
Allergies:  YesNoEpi-pen Required:  YesNo
Other Medical Conditions:  YesNo 

Please explain:  

Please list any other ailments that the staff should be aware:
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