Email
If you are a hospital employee, please use your company email.
Password
Account Type
Choose...
Patient
Employee
Next
First Name
Enter your name as it appears on your license.
Last Name
Enter your name as it appears on your license.
Date of Birth
Address Line 1
Address Line 2
City
State
Zip
Choose your biological gender
Male
Female
Medical History
Check all that apply to you or your family history.
AIDS/HIV Positive
Alzheimer's Disease
Anemia
Asthma
Blood Disease
Cancer
Convulsions
Diabetes
Drug Addiction
Epilepsy/Seizures
Headaches
Herpes
Heart Attack/Failure
Hepatitis
High Blood Pressure
High Cholesterol
Hypoglycemia
Leukemia
Liver Disease
Low Blood Pressure
Osteoporosis
Psychiatric Care
Recent Weight Loss
Renal Dialysis
Shingles
Stroke
Thyroid Disease
Tuberculosis
Yellow Jaundice
Of the items checked above, which affect you personally?
Please list any allergies you have.
Please list any medications you take.
Please upload an image of the front and back of your insurance card.
You must upload 2 images- front and back of your card.
What is the name of your family doctor?
Doctor's Address Line 1
Doctor's Address Line 2
City
State
Zip
What is your doctor's phone number?
Check here to acknowledge that you voluntarily share this information with QuickER to send to your preferred ER.
Register
First Name
Enter your name as it appears on your license.
Last Name
Enter your name as it appears on your license.
Enter your QuickER partner code.
This is the 6 digit code given to your hospital to connect employees to their database. It is unique to your hospital.
Type of degree
Choose...
DCM
DClinSurg
DMSc
DO
DS
MBBS
MCM
MD
MM
MMSc
MS
MSc
PhD
Nursing
Other
Specialty
Choose...
Cardiology
Emergency
Gastroenterology
General
Geriatrics
Gynecology
Infectious Disease
Internal Medicine
Neurology
Orthopedic
Pediatric
Plastic
Thoracic
Trauma
Urology
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