(Fields marked * are mandatory)
User Details
Provider Type *
First Name * Last Name *
Email *
(This will be your user ID)		 Email
Confirmation *
Your Password must contain:
At least 2 special characters (!@#$%^&*)
At least 2 capital letters
At least 2 numbers
At least 7 digits long
Password * Password
Confirmation *
Security Questions
Question #1 What city were you born in?
Answer #1 *
Question #2 What is your favorite color?
Answer #2 *
Question #3 What was the name of your favorite pet?
Answer #3 *
Question #4 What is the make and model of your first car?
Answer #4 *
Question #5 What is your favorite food?
Answer #5 *
   I certify that I have read and understand the following:
              Terms of use statement
              My rights under the Health Insurance Portability and Accountability Act (HIPAA)
              InstaHEAL's privacy policy
 
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