Date:  
 Location:  
 Department:  
 Clinic Information:  
 Physician:  

 
*Use PassPort Number or NewBorn:
*Please Enter your Chart No, Insurance Number or PassPort Number:
*If you are Return Visitor, please Enter your Birthday: Year: Month: Day:
 Please enter the code displayed in the image.
     (It's case sensitive)

     
 
Attention Please:

*If you are Return Visitor, please enter both * Fields.
*If you are First Visitor ,please enter your Insurance ID or PassPort Number in ID field.
*If you are don't have Insurance ID or ChartNo, please choose 'Use PassPort Number or NewBorn' item and enter your PassPort number in ID Field.