- Even if you signed up online, you still need to print, complete and bring the consent form. - Bring your MEDICAL insurance card. - If you do not have medical coverage through BHP (Anthem), bring $30 cash (use N/A as member ID below) - Note: no children ______________________________________________________________________________________________________

Clinic Location
First Name
Middle Name
Last Name
Date of Birth
 
 
Email
Confirm Email
Mobile Phone Number
Roster Billing Information
Member ID
Employee/Spouse/Other
Services I'd like to receive
You will receive those immunizations as medically indicated by your health consultant staff. Vaccine Information Statements are available online here.




Need help? Contact us at Flu@passporthealthoki.com