STATE 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
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
What is your birthday? *

YearMonthDay
Date
Where do you want your medical card mailed, IF APPLICABLE (No P.O.Boxes)
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. 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

My Products*

New Patient or Renewal

$75.00 Quantity

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

JIFFY PATIENTS