Archbold Patient Connect Access Request

Archbold Patient Connect Access Request

Have you attempted to self-enroll for Archbold Patient Connect? It is the quickest and most convenient way to access the portal. If self-enrollment did not work or you are having trouble, please fill out the below form.
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Last 4 Digits of SSN#
Medical Record #
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Primary Phone Type
Secondary Phone Number
Secondary Phone Type
Primary Email Address
Primary Email Address Confirmation
Secondary Email Address
Preferred Method of Contact

EmailPhoneText
By clicking SUBMIT, I certify that I, as the enrollee, have read, understand and agree to the terms and conditions in the Patient Portal Access Request on the previous page and intend this to be my legally binding signature.
Signature

Clear
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