Regular Form

JIFFY PATIENTS

Welcome to Jiffy Doctor! We are grateful to you as our valued patient. Let's get you registered!
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Yes, I need your help.No, I will upload my own files.
If we are processing you, what is the OMMA Password you used to create your account?
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your birthday? *

YearMonthDay
Date
What is your Driver's License Number? *
When does it expire? *
PLEASE upload the FRONT of your Driver's License here:

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PLEASE upload the BACK of your Driver's License here:

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If you answered yes to being a disabled veteran, please upload proof of your disability.

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If Jiffy is processing you, please upload your Medicaid, Medicare or SoonerCare card here (this makes your State fees $22.40 instead of $104.30):

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Where do you want your medical card mailed, IF APPLICABLE (No P.O.Boxes)
Please upload the front and back copy of your payment method for Jiffy Doctor to pay your State Fees (IF APPLICABLE) unless you are going to pay it yourself.

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Jiffy Doctor - Patient Registration

THE TIME YOU CHOOSE IS NOT YOUR DOCTOR'S APPOINTMENT TIME. IT IS FOR OUR PROVIDER TO REVIEW YOUR INFORMATION. IT IS NOT YOUR DESIGNATED PHONE CALL TIME. WE WILL CALL YOU THE SAME DAY OF YOUR APPOINTMENT. OUR CUT OFF TIME IS 5:00 P.M. IF YOU REGISTER AFTER 5 P.M., YOU WILL BE CALLED THE FOLLOWING DAY. PLEASE ADD 405-655-8028 TO YOUR CONTACTS. IF YOU MISS YOUR APPOINTMENT AFTER THE THIRD TRY, THERE ARE NO REFUNDS. DO NOT SIGN UP MORE THAN ONCE. WE CAN NOT REFUND YOU IF YOU DO SO. THANK YOU! YOUR CREDIT CARD STATEMENT WILL SAY NV CREATIVE ENTERPRISES, LLC WHICH IS OUR PROCESSOR.
Signature

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MOST STATES NOW REQUIRES YOUR SOCIAL SECURITY NUMBER. PLEASE ENTER IT HERE OR WE CAN NOT PROCESS YOU. YOUR FORM IS ENCRYPTED AND HIPAA COMPLIANT.
Please upload your picture on a white background if we are processing you with the State:

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My Products*

$49.99 Returning Jiffy Doctor Patient Recommendation (Must be a current patient)

$49.99 Quantity

New Patient

$100.00 Quantity

Renewal Patient

$75.00 Quantity

FULL SERVICE PROCESSING

$20.00

Total

$0.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Should be Empty:

JIFFY PATIENTS

Jiffy Doctor - Patient Registration