Deactivate PatientPortal - STI

1-800-487-9135 sales@sticomputer.com

Deactivate PatientPortal

PatientPortal Deactivation Form

Practice Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Deactivation Date*
MM slash DD slash YYYY
Reason for deactivating the PatientPortal:*
Contact Name*
First Last
Contact Email*