All fields marked * are required.
A valid, active email address is required to self-register.
Physician Registration
Personal Information  
* First Name Middle Name
* Last Name Suffix  
* Medical License Number * Issuing State
* Address as on license
* State * City * Zip -
The contact information provided below will be used only within EDRS to contact you and will not be shared among any other systems.
* Telephone Number 1  Ext:
Telephone Number 2  Ext:
Telephone Number 3  Ext:
* Email Address Fax #
User Access Information  
* Desired Username
* Password
* Re-type Password
The password must have at least eight (8) characters made up of uppercase and lowercase letters, numbers, and symbols (#, @, %, *, etc.). Avoid using personal information or common words.
* Secret Question 1 * Secret Question 2
* Secret Answer * Secret Answer

Before continuing to the next screen, please make a note of your username and password for future reference. They will be required to access NJ-EDRS at all times.
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  This system is restricted to authorized users. Random audits are routinely performed.
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