Dashboard | Texas Diagnostic Laboratories

QuickMD, LLC / QuickMD, LLC

Create Your Patient Profile

Fill all fields data carefully.

Patient Information

Patient's First Name *

Patient's Middle Name

Patient's Last Name *

MRN

Street Address *

Street Address 2

State *

City *

Zip Code *

Cellular Phone Number

Patient's Date of Birth *

Gender *

Ethnicity *

Race *

Government Issued ID #

Upload Image of License or ID

Upload

PLEASE CHECK IF APPLICABLE

The patient is a Minor

The patient is over 18

Insurance Status (if applicable):

No Insurance

Insurance

Primary Insurance *

Relationship *

Group Number

Insurance ID/Account Number *

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Street Address *

Press the search icon to lookup and autocomplete your address!

Street Address 2

State *

City *

Zip Code *

Secondary Insurance

Relationship

Group Number

Insurance ID/Account Number

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Street Address *

Press the search icon to lookup and autocomplete your address!

Street Address 2

State *

City *

Zip Code *

Tertiary Insurance

Relationship

Group Number

Insurance ID/Account Number

First Name *

Middle Name

Last Name *

Date of Birth *

Gender *

Street Address *

Press the search icon to lookup and autocomplete your address!

Street Address 2

State *

City *

Zip Code *

Upload an image (or, if on mobile, take a picture) of the front of your insurance card

Upload

Take a picture of the back of your insurance card

Upload

Attachments

Add attachments to this Patient's Profile.

Medical History

Prescribed Medication

Allergy

Medication Comments

Note

Texas Diagnostic Laboratories

QuickMD, LLC / QuickMD, LLC / Add Patients

QuickMD, LLC / QuickMD, LLC

Create Your Patient Profile

Patient Information

Patient or Parent/Guardian

Attachments

Medical History