Friday-October 20, 2017 
    
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IIC Registration Form
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 Login Information
UserName*
Password*
 Member Personal Information
Last Name*
First Name*
M.D./D.O.?
Speciality*
Hospital
Email
 Address Information
Address1
Address2
City
State
ZIP Code
Telephone*
 Other Information
Hospital Staff Priviledges
Board Certified Yes No
Name of the Board
 Patient Privacy

YSC's Internet Informed Consentâ„¢ will provide a place for you to input your patient's name, DOB, and any additional information. Please understand that this data is never transferred, collected, or stored on any computer anywhere. These data are simply placed into a temporary "buffer" and removed from "your" computer after exit or disconnect from the web page. If you have any specific questions regarding this please do not hesitate to contact us at