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Patient Registration
* indicates a required field
Patient's Name
First Name *
Middle Name
Last Name *
Patient's SSN, DOB, Gender
SSN *
DOB *
Gender *
Patient's phone number and time zone
Mobile Phone *
(This will be used to receive messages from Annie.)
Time Zone *
Alaska (GMT-09:00)
Atlantic (GMT-04:00)
Central (GMT-06:00)
Chamorro (GMT+10:00)
Eastern (GMT-05:00)
Hawaii-Aleutian (GMT-10:00)
Mountain (GMT-07:00)
Pacific (GMT-08:00)
Samoa (GMT-11:00)
Home Phone
Email
Email Address
Preferences *
How Patient will Receive Messages from Annie
Has Basic Cell Phone
Has Smart Phone
Basic or Smart Phone
Agrees to Receive non-secure SMS Text Messages
Agrees to Patient Consent Form
Submit
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