Nation Rx Advocates, LLC.

Patient Registration

First Name *

Middle Initial

Last Name *

Email *

Password *

Password must be min 8 characters
Password must contain characters (a-z and A-Z)
Password must contain digits (0-9)
Password must contain special characters (!$#%)

Phone

Is this a smart phone that can receive text?

What is the best time of day to contact you? *

Address *

Address Line 2

City *

State *

Zip *

Time Zone: *

Date Of Birth (mm/dd/yyyy)*

Sex *

Height Ft.

Height In.

Weight lbs

Ethnicity *

Ethnicity Other

Emergency Contact

First Name

Last Name

Phone

Relationship

Would you like to add your insurance information?

Policy Holder *

First Name (if not Self) *

Last Name (if not Self) *

DOB (if not Self) *

Insurance Name *

Insurance Type *

Member ID

Group Number

Add Secondary Insurance

Policy Holder

First Name (if not Self)

Last Name (if not Self)

DOB (if not Self) *

Insurance Name

Insurance Type

Member ID

Patient requests to be assigned to a physician, via telemedicine service, as the primary provider for this test request.

Patient requests to be assigned to a physician, via telemedicine service, if their PCP does not respond to the test request

Patient requests test review by PCP only

Primary Care Physician

Search for Primary Care Physician

First Name

Exact name, or wildcard * after 2 characters

Last Name

Exact name, or wildcard * after 2 characters

Organization

Exact name, or wildcard * after 2 characters

City

Exact city, or wildcard * after 2 characters

State

Postal Code

Add a New Primary Care Physician (PCP)

New Primary Care Physician

PCP First Name *

PCP last Name *

PCP NPI Look Up NPI

PCP Practice Name/Institution

PCP Phone

PCP Fax

PCP Address

PCP City *

PCP State *

PCP Zip

Patient Personal ID Card Front
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Primary Insurance Card Front
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Primary Insurance Card Back
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Secondary Insurance Card Front
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Secondary Insurance Card Back
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Notes

Select a Parent Patient

Patient Registration