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Patient Submission Form
Please provide as much information as possible.
Clinic Name Doctor Name
*
Please enter the Clinic name
Your Email Address
*
example@example.com
Patient Information
EMR ID
*Only for clinics with existing EMR integration
First Name
*
Middle and Last Name
*
Date of Birth
*
mm/dd/yyyy
Insurance Number
*
Street
*
City
*
State
*
Zip
*
Phone
*
3455558534
Diagnosis Code - Hypertension
Diagnosis Code - Diabetes
Diagnosis Code - Pulmonary
Diagnosis Code - Other
Device Type (if device is being deployed in clinic)
Blood Pressure
Device Glucometer
Weight Scale
Pulse Ox
Serial Number of Device
Submit
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