Patient First - Portal Access Request Form

Occupational Health Portal Access Request Form

IMPORTANT: Before requesting portal access employers must first establish an Industrial Client (I.C.) Account. To establish an IC account contact your Sales Manager.

First time users: Establish a portal account by completing the following application. New users will receive an e-mail with a portal activation code and onboarding instructions within 1-3 days.

Company Name

Company Address

Please enter company address including city, state, and zip code.

Company Contact

Title

Email Address

Email Address (verify)

Contact Telephone Number

Please enter your direct number or cell phone number including area code.

Account IC # (if known)

Activation PIN

Please enter a unique activation PIN (personal identification number) and retain it for your records. A PIN must be between one and six characters. A PIN is a security code for verifying your identity. Similar to a password, your PIN should be kept private.