Forms

Please select your Role.

Patient: Choose this role if you are a certified patient, eighteen years of age or older, and capable of consenting to your own medical treatment.

You may also use this role if you are helping a patient register who is eighteen years of age or older and the patient can consent to his or her own medical treatment.

Proxy Applicant: Choose this role if you are registering on behalf of a patient who is under the age of eighteen or on behalf of a patient who is incapable of consenting to medical treatment.

• You must be over twenty-one years of age to select this role.
• If you are helping a patient register who is over the age of eighteen and can consent to their own medical treatment, do NOT select the Proxy Applicant role.

Caregiver: Choose this role if you were designated by a patient or a proxy applicant on the patient’s registration to be a patient’s caregiver.