Merge / Duplicate Form

* indicates required field

Contact Information

Name *

First

Last

Location *

Phone # *

Email *

If you would like for us to contact you after the merge has been completed please let us know your preferred method of being contacted:

Phone Call
Email

Patient Information

Please enter the details of the patient record to be merged below

Patient Name: *

First

Last

Patient DOB:

Input the MRNs to be merged below.

MRN *

MRN

Notes:

Only those individuals who have been authorized by NWR to access NWR systems, applications and data are allowed to do so and must always comply with all NWR policies and applicable laws.

Unauthorized or inappropriate access is strictly prohibited and will result in termination of access and possible prosecution.