NEW USER REGISTRATION 5/5/2025 4:21:50 PM

Account No

First Name* Last Name*  Birth Date *  / /

Occupation

Sex Male  Female Mr Ms Mrs Marital Status  Single Married Other

Spouse First Name Last Name  DOB // MF Married

Address* Address1

ZIP + City* State* Country*

Home Phone Cell Phone Work Phone

Email

Confirm Email*

User Id* (8-16 characters)

Password* (8-16 characters)

Confirm Password*

Security Question* Your favorite color? Your favorite city? Your favorite singer? Your pets name?

Security Answer*   OPT-IN SMS I CONSENT THAT I HAVE READ AND AGREE THAT MY DATA BEEN PROCESSED AS IN DESCRIBED IN THE TERMS OF SERVICE AND PRIVACY POLICY I CONSENT TO RECEIVE SMS ALERT AND NOTIFICATION FROM PGUPTAMD.COM I CONSENT TO RECEIVE MARKETING SMS MESSAGES FROM PGUPTAMD.COM

(Every member of the family above 18 years will need to register Separately )

OTHER MINOR FAMILY MEMBERS First name Last name Date Of Birth Sex Relation Marital Status // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other  // MF Select Son Daughter Single Married Other