Pickens county primary care: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin by printing your name and birthdate in the designated fields. This information is required for identification purposes.
Next, provide the name of the responsible party or legal guardian along with their phone number. Ensure that this information is accurate as it may be used for communication regarding your portal access.
Enter a personal email address clearly in the specified field. This email will be used to send you an invitation to set up your patient portal account.
Review the purpose and functionality of the patient portal outlined in the form. Understanding how it works will help you utilize it effectively once access is granted.
Sign and date the acknowledgment section at the bottom of the form, confirming your understanding and agreement to participate in the patient portal.
Finally, deliver, send, or fax this completed form along with a copy of your photo ID to the Medical Record Department at Pickens County Primary Care.

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