Name: | DOB: | MRN: | PCP:

Register by Mail

Please fill out the form below. All fields are required to verify your identity with Wake Forest Baptist.

This form may only be used to request an account for you. To protect our patients' privacy, you need authorization to access a family member's or other individual's health record. Parents, guardians, spouses, adult children or partners who need access to another account may request Proxy Access. Please read Proxy Access Instructions.

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Once verified, we will mail your code to the address indicated above. This can take 5-7 business days. If we have any questions about your information, we will contact you at the home phone number above.

If you need help, please contact the myWakeHealth Patient Support Line toll-free at 855-560-5111.