New Patient Registration | Wellness Health

Wellness Healthcare

Today's Date:

Create Account
First Name:
Middle Initial:
Last Name:
Gender:	male female other
Date of Birth:
Social Security Number:

Patient Contact Information
Address Line 1
Address Line 2
City:
State:
Zip Code:
Email Address:
Phone Number:

Patient History
Have you ever had (Check all that apply) :	Diabetes Asthma Covid-19 Tuberculosis Hepatitis
If you selected any of the above, please explain:
Have you been vaccinated?	yes no
Do you have health insurance?	yes no
How would you rate your overall health? (Rate from 1 to 10)

Patient Portal Account
User ID:
Password:
Confirm Password: