Welcome to ScheduleMD - Your Online View of Your Physician

Enroll With ScheduleMD. Please complete the following information and click the enroll now button.


Enrollment Code :
Last Name:
First Name:	MI:
Address:
City:
State:
Zip Code:
Phone:
Email Address:
**This email address will also be your login username
Confirm Email:
Password:
Confirm Password:
**Passwords must be at least 6 characters in length
SSN:
Sex:
Birthdate:
Select Provider:

Please add your credit card information by using the credit card graphic as a guide.
Name on the Card:
Credit Card Number:
Card Security Code:
Expiration Date:
Card Type:

Authorization: By checking this box and submitting this information I confirm that I am at least 18 years old and have read and agree to the Enrollment Terms and Conditions and Financial Policy. I authorize ScheduleMD, LLC or its relevant customers to debit or credit the enrolled account I use to schedule my appointment as it applies to co-pay amount or non-cancellation fee(s), should it apply.

I authorize ScheduleMD to debit or credit my enrolled account and/or credit card. I authorize the listed payee when my account is used per the Financial Policy of the medical practice to debit my account for the amount indicated in the tender amount of my payment transaction. In the unlikely event this transaction for the amount tendered is returned unpaid I agree that a return fee may be collected by the same electronics means as allowable by State's law. I understand that this authority is to remain in full force and effect until the Company has received written notice from me of its termination in such time and such manner as to afford the Company a reasonable time to act on it. ScheduleMD, LLC Privacy and Security

I ACKNOWLEDGE THAT I HAVE VOLUNTARILY PROVIDED CERTAIN INFORMATION TO SCHEDULEMD IN ORDER TO ADHERE TO THE FINANCIAL POLICY OF THIS MEDICAL OFFICE. I FURTHER ACKNOWLEDGE THAT NO INFORMATION WILL BE TAKEN FROM MY ENROLLMENT TO CREATE A DATABASE THAT WILL IDENTIFY ME "PERSONALLY" AND IS NOT IN CONFLICT WITH "HIPAA" RULES AND REGULATIONS REGARDING MY PRIVACY. THE INFORMATION PROVIDED WILL BE USED ONLY TO VERIFY MY IDENTITY AS AN ENROLLEE IN THE PRACTICE MANAGEMENT SYSTEM PROVIDED BY MY MEDICAL PROVIDER