Independence Health & Therapy

Security Check

Instructions: We value your privacy! To select the right provider, check insurance coverage, and expedite the intake process, complete the form to register as a new client. If you have an HMO call our office.

First Name:*

Last Name:*

DOB:*

Sex:*

E-mail:*

Mobile #:*

Home Phone #:

Address:

Zip Code:

Patient Availability:

Days:

Sun Mon Tue Wed Thu Fri Sat

Referral Source:*

Reason for Visit:*

Facility:

Get email instructions in:

English Spanish

Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

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Once clicking "Proceed to Registration", you can complete your registration now or return to complete it later by clicking the link in the initial email you received.

It seems like you are trying to access Patient Portal using Browser.

You will be happy to know that Patient Portal works seamlessly with Google Chrome.

Do you want to download
Google Chrome
now?

You can even make Google Chrome as your default browser.
Do you want to make Chrome your default browser?

If you want to see the step-by-step process to download
Google Chrome, click on the Download PDF button.

Still if you don’t want to use Google Chrome and continue with at the moment

Allow Cookies

When you open Patient Portal in Incognito mode, third-party websites cannot access data if the cookies are blocked. You will need to allow cookies to work seamlessly with portal.

It seems that the cookies are blocked on your system. If you want to know the step-by-step process to learn how to allow cookies...