Please complete the following form to request an account. Items marked with a
*
are required.
Your
Username
must be the patients's
first name initial + last name initial + Date of Birth
.
Example: the username for John Smith who was born on May 1st 1980 will be
JS050180
First Name:
Last Name:
*
Email Address:
*
Username
(see note above)
:
*
Password:
*
Confirm Password:
If you're already signed up, please
CLICK HERE
to proceed to the Main Menu page.
.
