DocFlight Patient Sign Up

This form helps us collect your personal and medical information. The more accurate and complete information you provide, the better we can serve you.

Items marked with an asterisk (*) are required





Personal Details
Your Name *
Birth Date  
Gender  
Billing Address
Address *
Address (line 2)  
City *
State/Province
Zip/Postal code
Country *
Contact Information
WeChat Account
Phone
E-mail address *
Account Details
Username *
Password *
Confirm Password *
Passwords must contain at least eight characters and include one digit, one lower case character and one upper case character.
Image verification
Type the characters you see in the picture
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  Please send me information related to my health care, health insurance or site updates!
  I have read and AGREE with Terms & Conditions


 

NOTE:
We recommend that your password should be at least 8 characters long and should include at least one number, one lower case character and one upper case character.

All your private data is confidential. We will never sell, exchange or market it in any way.