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Facility Registration
Register Your Organization
1
FACILITY INFORMATION
2
ORGANIZER INFORMATION
3
CLINIC SCHEDULE
4
ADD PATIENTS
FACILITY INFORMATION
Facility Name
*
Phone
*
Website
Address
*
City
*
State
*
California
Zip
*
County
*
Select
San Bernardino
Los Angeles
Orange
No. Of Patients
Event Location
Who will be signing the consent to treat ?
*
Patient will sign
Facility on behalf of patient
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ORGANIZER INFORMATION
First Name
*
Middle Name
Last Name
*
Title
Email Address
*
Retype Email Address
*
Direct Phone
Cell Phone
*
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CLINIC SCHEDULE
STEP
#1
SELECT 3 PREFERRED DATES
STEP
#2
SELECT 2 PREFERRED TIME SLOTS
11:00 AM
to
12:00 PM
12:00 PM
to
01:00 PM
01:00 PM
to
02:00 PM
02:00 PM
to
03:00 PM
03:00 PM
to
04:00 PM
04:00 PM
to
05:00 PM
STEP
#3
SERVICE TYPE
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ADD PATIENTS
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