Client Portal Request Form
Please fill in your information below. Once we receive your request you will receive an email inviting you to finalize your registration. Note: If a client is 18+ only the client can activate their portal account. For minors the portal account is assigned to whoever is listed as the Responsible Party on the account. Once you set up your account your can easily add a proxy or consent for someone else to access the portal account. Please contact kjvalerius@sundstromclinic.com for any questions.
Portal account type:
Client (18+)
Responsible Party (Client 0-17)
Clients 18+ Years Old
Complete this section if you are a client 18+ years old.
Client's First Name:
Client's Last Name:
Client's Email:
Clients 0-17 Years Old: Responsible Party
Complete this section if you are the Responsible Party to a minor client.
Client's First Name:
Client's Last Name:
Responsible Party's Full Name:
Responsible Party's Email:
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