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The Performance Doc Portal
Install App
Recaptcha v3
New client registration form
E-Mail - This will be your Username
Required
Birthday
Expected format: MM/DD/YYYY
Required
What is your limitation?
Required
Appointment Location
9611 Sherrill Estates Rd Huntersville NC 28078 | M-Th: 7am - 6:30pm F: 7am - 3pm
Required
Referring Provider
First Name
Required
Middle Name
Last Name
Required
Gender
Female
Male
Required
How did you hear about us?
Chiropractor
Doctor
Facebook
Friend/Family
Google or Search Engine
Gym
Instagram
Other
Patient Referral
Seminar/Workshop
Yelp
Required
Home Address
Required
Apt, Ste, or Floor (Optional)
City
Required
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Required
Zip Code
Required
Phone Number
Required
Phone Type
Cell
Home
Work
Required
Insurance - If applicable
Self Pay / No Insurance
6 Degrees Health - 6 Degrees Health Plan
Aetna - Aetna Plan
AG Administrators - A G Administrators Plan
American Health - American Health Plan
American Retirement Life Insurance Company - American Retirement Life Insurance Company Plan
Amerihealth - Amerihealth Plan
Anthem BlueCross - Anthem BlueCross Plan
BCBS - BC/BS Plan
Cigna - Cigna Health and Life Plan
Cigna - Cigna RPN
Cigna Medicare - Cigna Medicare Plan
CSI - Central States Indemnity Plan
First Agency Inc - First Agency Inc Plan
GPA - GPA Plan
GPM Health and Life Insurance Company - GPM Health and Life Insurance Company Plan
Healthy Blue North - Healthy Blue North Plan
Heartland National - Heartland National Plan
Humana - Humana Plan
Medcost - Medcost Plan
Medicare - Medicare Plan
Meritain Health - Meritain Health Plan
NC Medicaid - NC Medicaid Plan
New York State Health Insurance Program - New York State Health Insurance Program Plan
RAILROAD RETIREMENT MEDICARE - RAILROAD RETIREMENT MEDICARE Plan
Thrivent Independent - Thrivent Financial Plan
Transamerica - Transamerica Plan
Trustmark - Trustmark Health Benefits Plan
UHC Community Plan - UHC Community Plan Plan
UHC Golden Rule - UHC Golden Rule Plan
United American Insurance Company - United American Insurance Company Plan
United Healthcare - United Healthcare Plan
United Healthcare Empire Plan - United Healthcare Empire Plan Plan
United World Life Insurance Company - United World Life Insurance Company Plan
USAA - USAA Plan
Zenith - Zenith Insurance Company Plan
Member ID
Required
Group Number
Are you the policy holder?
Yes
No
Required
I have a secondary insurance policy and will provide details upon arrival
Other Insured
Please provide the policy holders information. For example, if this is your spouses policy you would enter their information in the corresponding fields below.
Policy holder First Name
Required
Policy holder Middle Name
Policy holder Last Name
Required
Relationship to insured
Child
Other
Spouse
Employee
Unknown
Life Partner
Mother
Required
Policy holder Gender
Female
Male
Required
Policy holder Birthday
Expected format: MM/DD/YYYY
Required
Policy holder Address
Required
Policy holder Suite, PO Box, etc.
Policy holder City
Required
Policy holder State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Required
Policy holder Zip Code
Required
Password
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