Patient Portal Registration - Montrose Regional Health

Register for Our Online Patient Portal

By completing this registration form, you understand that you are attempting to gain access to records held at Montrose Regional Health in Montrose, Colorado.

"*" indicates required fields

Phone

This field is for validation purposes and should be left unchanged.

Patient Name*

First Last

Patient's Date of Birth*

Phone Number*

Email Address*

Last 4 Digits of SSN*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Name (if applicable)

First Last

By signing and dating this form, I am authorizing Montrose Regional Health to create a patient portal Logon ID and password for the patient listed above. I understand that this information will be emailed to me within 3 business days at the email I have given above.

Patient E-Signature*

Please sign using your full legal name.

Today's Date*

Confirm Registration Form Sign-Up

Whenever a new item is posted to your patient portal, such as results, reports, appointments etc., you will receive an email notification. There will be a link at the bottom of the email directing you to the portal log-in screen. No health information is relayed in any email. All email addresses will be kept confidential and will not be used for marketing or solicitation. You may go to the Patient Portal page on our website to access your portal or to learn more about the patient portal. You will submit this form by clicking on the "submit" button below.

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Patient Portal

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