MedicsPremier - Patient Portal

New Patient

13260 N. 94th Drive
Suite 100
Peoria, AZ 85381

19820N. 7th Street
Suite 140
Phoenix, AZ 85024

PH: 623-487-7763
Fax: 623-486-8276

Patient Profile

Please type in your information below.

First Name: *

Middle Name:

Last Name: *

Date of Birth: *

Sex: *

Home Phone Number: *

Mobile Phone Number:

Street Address: *

Apt/Suite/Other:

City: *

State: *

Zip Code: *

Fields marked with a (*) are required.

Online Account

Please select a username for your online patient portal account below.

Username: *

E-Mail: *

Password: *

Confirm Password: *

Passwords should be a minimum of eight (8) characters.

Fields marked with a (*) are required.