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If you would like to be listed on the Family Patient website, you can set up an account by completing the registration form below. After your registration has been submitted, your account will become active immediately. (However, the information you submit will be reviewed and verified for accuracy by one of our staff members later, so please make sure you check all information before you submit your registration.) Please review the Terms and Conditions of Use of the Family Patient website before you register.

After your registration has been submitted, you will be emailed the Account Manager Login, which will allow you to add/update Patient Update Reports, and update your account information. A separate Visitor Login will also be sent to you and to everyone on the list of email addresses you provide in the Visitor Login box below, which will allow authorized Visitors access to your patient's private Update Reports.

Family Patient has services available to patients and families who need assistance getting their Update Reports posted, or who do not have access to an internet connection. Please contact us to find out about these services.

Before registering a patient, we highly recommended that you review the Demo Patient which will guide you through the features of the Family Patient website. You may also wish to review the detailed instructions for filling out this registration form.

The information you enter below will remain completely confidential, and will only be used for internal administration, contact, and verification purposes. Please read our Privacy Policy if you have any questions about the use of the information being submitted.

(*Required Information)
PATIENT INFORMATION:
*Patient First Name: 
*Patient Last Name: 

ACCOUNT MANAGER INFORMATION:
Please provide the contact information for the person who will be responsible for the management of this account:
*First/Last Name: 
*Address1: 
Address2: 
*City: 
*State: 
*Zip: 
*Phone: 
*Email: 
 (Please enter only ONE email address - the Account Manager login will be sent to this email address)

MEDICAL INFORMATION:
Please give the location and name of the Hospital/Facility where the patient is staying:
*State: 
*City: 
Hospital/Facility Name: 
Room Number: 
Primary Physician: 
*Patient's Diagnosis:

VISITOR LOGIN:
Enter the email addresses of people to whom you would like to send the Visitor Login (you can choose to create your Email List later).

Please be sure to check the accuracy of the email addresses you list. Please enter one address per line. You may enter up to 50 email addresses. All email addresses you enter will be saved - regardless of whether you choose to send the Visitor Login to them now or later.

Check to send the Visitor Login to everyone on this list now.

ALLOW PATIENT UPDATE REPORTS TO BE VIEWABLE TO THE PUBLIC:
You can choose to have your Patient Update Reports be viewable in the Public Update Reports area of the website. If you choose to make the Reports public, ONLY THE FIRST NAME OF THE PATIENT WILL APPEAR IN THE REPORT.
Check to allow your Patient Update Reports to appear in the Public Update Reports area

ONLINE MESSAGING SYSTEM:
You can allow Visitors to send messages to the Patient via our internal Messaging System. A "Send a Message to this Patient" button will appear within the Update Report pages, allowing the Visitor to send a message to the Patient.
Check to allow Online Messaging from Visitors who have logged in
Check to allow Online Messaging from people viewing Public Update Reports

Please verify this form by entering the following letters: GQLNG

I have read and agree to the Terms and Conditions of Use of the Family Patient website.

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