My PHP Account - Registration Form

Please fill out all fields listed under "Required"

Required Account Information

Format: 000-000-0000
DOB Is Used For Authentication Only, Format: MM/DD/YYYY
Email address must be unique
Emails provided must match
Password Requirements: 8 Characters
Passwords provided must match
Read Terms of Use

Optional Account Information

Required Provider Portal Information

Please select only the practice locations you are affiliated with and need access to.

Click on an individual item to move it from one box to the other.
Click the double arrow button to move all items displayed in one box to the other. Use the filter bar above each box to filter the items displayed in a box.

Left Box = Not Selected | Right Box = Selected

Top Box = Not Selected | Bottom Box = Selected

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