Request a BVIHSA Patient Portal Account

Patient Portal Request Form

Name *

First

Last

Record To Address

Date of Birth *

You must be 14 years or older

Sex

• Male
• Female

Email Address You Would like to Connect Your Medical Record To *

Phone

Address

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City

State / Province / Region

Postal Code

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Identification Verification *

Click or drag a file to this area to upload.

Please upload a copy of your Driver’s License, Passport, Birth Certificate, Voter’s ID, Work Permit Card or Belonger Card.

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