Clinic Signup

In order to register your clinic - for the first time - with CCHF, please fill out your contact details.

Once this step is completed, you'll be taken to the clinic profile form, where you can complete the details about your clinic.

PLEASE NOTE: We require your last 4 digits of your Social Security number to verify your identity and keep your clinic information safe.

First Name

Middle Name

Last Name

Suffix

Job Title

Birthdate

MM/DD/YYYY

Last 4 Digits of Soc Sec Number

Mobile Phone

Work Email

Clinic Name

Let's see if your clinic is already in our system. Start typing the name of your clinic.

If your clinic is already in our system, you'll get an error message as this form is designed for new clinics only.

But no worries, we have a plan for that! Simply Click here and select the 'Update Primary Contact Form' to receive authorization to update your existing clinic data.

Clinic Name - New Clinic

Can't find your clinic name in the list? Enter it here to register a new clinic.

Billing Street

Billing City

Billing State

Billing Zip Code

Contact Information