LifeSource - Patient Portal Registration

Hello there!

LifeSource's online registration is exclusively available for current patients. To initiate the registration process, please enter the required information.

To ensure we are able to accurately match you in our system, please enter your first and last name exactly as it appears on your primary insurance card. Do not add your middle name in the first name field.

First Name

Middle Name

Last Name

Date of Birth

Primary Insurance Number

Last four of SSN

Patient Street Address

Contact Email

Contact Phone Number

Nickname

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If you would prefer not to use this form, you may call our office at (910) 742-9243 to register for the patient portal.