JMED PHA = New User Registration

Enter family's login info

User ID:

Password:

Please fill in with alphabets.

Personal Information

**Required Information

Last Name (Family Name)*

First Name*

Gender*

Date of Birth*

Marital Status*

Address*

Address 2

City*

State*

Zip/Postal Code*

Country*

Email*

Phone*

Cell Phone

Fax

Company Information

Company Name

Address

Address 2

City

State

Zip/Postal Code

Country

Phone

Ext

Fax

Emergency Contact

Last Name*

First Name*

Relationship*

Phone*

Submit

Clinic*

Security Question*

Answer

Other

Authorization for Information Disclosure and Insurance Payment Process

I authorize to disclose my health information obtained by the diagnostics, treatments and as the result of examination to the insurance company. I authorize to process the claim to the insurance company and payment to be made directly to the clinic to cover the fee of medical treatment that I receive. I also agreed to pay any fee not covered by the insurance to the clinic or the doctor in the timely manner.

Patient Information