Photo ID

Photo ID

We are required to obtain an updated copy of your valid ID annually, or when there have been changes to it. We accept a valid driver's license, military ID, government issued ID or passport. (If the patient is a minor, or does not have a photo ID, the parent or legal guardian should upload their own photo ID.)
Para ver este formulario en español, haga clic en el menú desplegable en la esquina superior derecha.
Patient's Legal Name*

First NameMiddle NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Age
EXAMPLE - Upload a clear and legible copy of both sides.
Upload a copy of your Photo ID Front and Back side*

Uploading this information will speed up your registration process. If you don't have the ability to scan your ID, you can take a picture with your cell phone and upload the photo(s). Be sure to take a photo of the front and back side of your Photo ID.
Cancelof
Today's Date

MonthDayYear
Date
Please verify that you are human*
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