You can only upload picture to this site. When our merger is complete, patients will be signed up to a patient portal for other request. Patients Name First Name Last Name Patient Date of Birth - Month - Day Year Date Phone Number In case we have a problem to call you or to text when complete * Data rates apply. Parent / Legal Gaudian First Name Last Name This form is HIPPA compliant and its submissions utilize HITRUST Notes Take Photo File Upload / Documents / Pictures Browse Files Drag and drop files here Choose a file Cancel of Your Finished Please select Submit to complete your request Submit Should be Empty: