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User Settings

ClientID

100000001

eMail Address*

first.name@mailer.com

Password*

***************

Client Name

Mobile Number*

+1 (999) 888-7777

Confirm Password*

***************

Personal Information

First Name*(legal)

First Name

Gender

Last Name*(legal)

Last Name

Date Of Birth*

MM/DD/YYYY

At least one is required if Client is under 18 or Client is incapable of using the Application.

Guardian 1*

GuardianID_1

Guardian 2

GuardianID_2

Guardian 3

GuardianID_3

Guardian 3

GuardianID_4

Relationship*

Mother or Father

Relationship

Father or Mother

Relationship

Guardian

Relationship

Guardian

Home Address

Street Address Line 1*

Street Address Line 1

City*

City

Zip Code (first 5)*

12345

County*

County

Street Address Line 2

State*

Pick State

Zip Code (next 4)

1234

Client Consent

Document

Consent to Participate in a Telemedicine Consultation

Consent to Terms of Use

Consent to Privacy Policy

BoticaNena HIPAA Marketing Authorization

Signed Date

MM/DD/YYYY HH:MI:SS

Protected/Personal Health Information (PHI)

Record Type

PCP - Provider NPI

Medical History

Insurance Information

Last Update Date

08/08/2008 08:08:08

*Required Fields

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