Practice Portal Enrollment Request
Practice Portal Enrollment Request
Practice Name
*
Name
Name
*
Title
First
Middle
Last
Suffix
Email
*
Phone
Phone
*
-
###
-
###
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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
Notes/Special Instructions