Patient Registration

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Patients registering will be administered by Dr Mark DiRe and Dr Whitney Bator. For more information regarding their office please click here
Enter the required fields below to complete your patient registration.

* Name
    
* E-mail Address:
* Username:
* Password
* Confirm Password:
* Phone
* Date of Birth
Who can we thank for referring you?
 
 
Are you completing this form for another person?
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* Verification Code
 

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After completing the fields and selecting the 'Submit' button below you will receive a confirmation message at the email address entered above. You will need to click on the activation link in your email before you can login to your account.
 
* I certify that the above information is correc