Proactive MD

New Portal Login Request

Please submit all required information below, including your employer in the Notes field.

After clicking SUBMIT, your request will be verified. Please allow one business day for this verification to be completed. Once verified, you will receive an email with your portal account login information. PLEASE check your SPAM/JUNK folders before submitting a second request.

* Required Fields

First Name *

Middle Name

Last Name *

Address *

City *

State *

Zip Code *

Phone 1 *

Ext

Type *

Email Address *

Confirm Email Address *

DOB *

Sex Assigned at Birth *

Patient Notes

Please enter characters in the picture below

Anti-Spam Code *

( Click Once )