Register for WorldMedcard

1: Select Username and Password

	Type a Username that you will remember to access your account.*		(Your Username is a 6 alphanumeric characters or longer word that you select that you can use to access your records.)
	Select a Password*		(Please use 8 or more characters)
	Retype Your Password*		Info on creating a valid User ID and Password
	Secret Question*		If you forget your User ID/password, this will be one way to retrieve it.
	Secret Answer*

You need to check all the boxes below
I accept the privacy policy (View Privacy Policy)
I accept the terms of use (View terms of use)
I accept the legal disclaimer (View legal disclaimer)

2: Essential Information about You

Your Name

Title

First Name*

Middle Name

Last Name*

Your Date of Birth*

Please use format MM/DD/YYYY

Sex/Gender

Address*

Address
(Apt/Suite/Other)

City*

State, use Province if not United States*

Province:

ZIP/Postal Code*

Country*

Phone#*

(Please use the following format for US numbers ###-###-####)

Emergency Contact Name

First Name*

Last Name*

Emergency Contact Phone#*

Your Email Address (please use lower case letters)*

We will Email A Copy of your Registration Materials to this address.

Nationality

3: Social Information

Do you smoke?	If "Yes", How Much?
Do you drink?	If "Yes", How Much?
Are you married?	If "Yes", what is your spouse name
Do you have children?	If "Yes", How Many?
Additional Information?

4: Select your institute

Please select a hospital or institution below. Highlight each hospital or institution you have visited and click add.

Your Institute		Select institutions or Select "no institutes".

5: Finish