Practice Portal Enrollment Request

Practice Name
Name Name Title First Middle Last Suffix
Email
Phone Phone - ### - ### ####
Role Requested - Select all that apply (If you need access to all 3, check all 3 role boxes).

Role Requested - Select all that apply (If you need access to all 3, check all 3 role boxes). None | User Folder Only (File Sharing) All Reports | Monthly Reports Folder Senior Health Connect Folder

You will receive an email notification when a file is uploaded to your User folder or to the Monthly Reports folder.
Notes/Special Instructions