Union Family Health Center -- Patient Portal Enrollment Request Form
Please complete this form in order to be enrolled in our Patient Portal.
If you would like to enroll your minor child, please contact the clinic directly at 702-437-0227.
Required fields are marked with a red asterisk.
Please contact AHC-ClinicOps@activatehealthcare.com if you have questions.
Date of Birth
Cell Phone Number
Please note that each patient requires a UNIQUE email address (i.e. multiple patients cannot have the same email address for portal purposes)
City, State, Zip Code
If you would like a confirmation of this submission to be sent to your email, please check the box below then re-type your email address.
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