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Patient Information

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Patient

First Name

Middle Initial

Last Name

Date of Birth

Legal Sex

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Preferred Phone

Mobile Phone

Work Phone

Address

Address line 2

House Number

City

State

ZIP Code

Social Security number

Email

Name Suffix

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Insurance Information

Indicates a required field.

Insurance

Insurance

Insurance Name

Member ID

Subscriber ID

Group Number

Subscriber Name

Subscriber Date of Birth

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Error: First name is required.

Error: Middle name is required.

Error: Last name is required.

Error: Name contains invalid characters.

Error: Spouse's last name is required.

Error: Spouse's last name first is required.

Error: Last name prefix is required.

Error: Spouse's last name prefix is required.

Error: Name suffix is required.

Error: Given name initials are required.

Error: Date of birth is required.

Error: Date of birth is invalid.

Error: Date of birth must be in the past.

Error: Legal sex is required.

Error: Race is required.

Error: Ethnicity is required.

Error: Preferred Language is required.

Error: Email address is required.

Error: Email address is invalid.

Error: Home phone is required.

Error: Phone number is invalid.

Error: Mobile phone is required.

Error: Phone number is invalid.

Error: Work phone is required.

Error: Phone number is invalid.

Error: Address is required.

Error: City is required.

Error: County is required.

Error: Please enter a county.

Error: District is required.

Error: Please enter a district.

Error: House number is required.

Error: State is required.

Error: Please enter a state.

Error: ZIP code is required.

Error: Zip code is invalid.

Error: Country is required.

Error: Please enter a country.

Error: Social Security number is required.

Error: Social Security number is invalid. The correct format is ###-##-####.

Error: Social Security number is required.

Error: Insurance is required.

Error: Insurance name is required.

Error: Member ID is required.

Error: Subscriber ID is required.

Error: Subscriber name is required.

Error: Subscriber date of birth is required.

Error: Subscriber date of birth is invalid.

Error: Subscriber date of birth must be in the past.

Error: Group number is required.

Error: Must be exactly 4 characters.

Error: Cannot exceed 18 characters

Error: Cannot exceed 20 characters

Error: Cannot exceed 25 characters

Error: Cannot exceed 40 characters

Error: Cannot exceed 50 characters

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Error: That username is not available

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Error: The retyped password doesn't match the original.

Error: Your username does not pass our custom requirements.

Error: Your username must be between @MYCHART@MINLEN@ and @MYCHART@MAXLEN@ characters.

Error: Your username must have at least 3 characters.

Error: Your username cannot contain any spaces or symbols other than a period (.), hyphen (-), underscore (_), or the at symbol (@).

Error: That username is in use already.

Error: Your password must contain at least one letter and one number.

Error: Invalid password. Please enter a different password.

Error: Your password must have at least 2 characters.

Error: Your password must be between @MYCHART@MINLEN@ and @MYCHART@MAXLEN@ characters.

Error: Your password must be different than your username.

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