Form

Set up a new account
First Name	Only letters, apostrophes or dashes.	Middle Initial	Upper Case.	Last Name	Only letters, numbers or dashes.
Birth Date
Social Security Number	- - Only numbers, must have 9 characters.			Phone Number	( ) - Only numbers, must have 10 characters.
Address Line 1	Only letters or numbers.
Address Line 2	Only letters or numbers.
City	Only letters	State		ZIP	Only numbers.
Email	Must include an @ and a . domain.
Describe your symptoms
Check previous illnesses Cancer Diabetes Hypertension Heart Disease Stroke
Gender	Male Female Other	Previous Customer?	Yes No	Do you have insurance?	Yes No
Rate your pain from 1 to 10	1 10
Desired User ID		User ID:		At least 5 characters, no spaces, first character not a number.
Password	Check password fulfills conditions and matches. ❌ Password contains user ID ❌ Password does not contain uppercase ❌ Password does not contain lowercase ❌ Password does not contain a number ❌ Password does not contain a special character ❌ Password is not at least 8 characters			Confirm Password	❌ Passwords do not match Check password fulfills conditions and matches.
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