UNtouchED Patient Portal

✨

Ready

Press the button below to begin a new patient intake.

Please provide your details below.

Title

First Name

Last Name

ID Number

Contact Number

Email Address

How did you hear about us?

For your medical record, please take a quick photo.

Camera not working?

Upload Photo

In order for me to give you the best possible results, please be so kind as to answer these important medical questions:

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I, [Name], hereby confirm that I have read and understood the above disclaimer.

Date

Signature

Timestamp: -
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I agree to the above terms and conditions.

Your information has been securely saved.

Please hand the tablet back to the receptionist.