Dendi | Patient Registration

Patient Demographics

Clinics/Locations

First Name

Middle Initial

Last Name

Suffix

Date of Birth

Phone (US-Only)

Gender

Ethnicity

Race

US International

Mailing Address

Apartment, Suite, Unit - Optional

County

City

State

Zip Code

Country

Add Dependents?

No Yes
Note: By adding dependents, you as the primary patient are consenting to allow orders to be created and testing performed for dependents.

If yes, you will be able to add your dependents on a separate page before completing registration. If you choose not to add dependents now during the registration process, you can do so within the Patient Portal after confirming your email and logging in.

Login Information

Note: In order to log in to the Patient Portal & receive notifications about test results, you will need to provide a valid email address. After registration is finished, you will be sent a confirmation email.

Password

Confirm Password

Patient Registration

Patient Demographics

Add Dependents?

Login Information

Patient Signature

Use the signature pad below: