First Name
*
Last Name
*
Preferred Name
If you don't have a preferred name that differs from your legal name, then leave blank.
Phone
*
Email
*
Date Of Birth
*
Address
*
Street Address
*
State
City
Postal Code
Sex
*
Sexuality
Gender Identity
*
Race
*
Ethnicity
*
Select all that apply
Student
Teacher
Active Military / Veteran
First Responder / Healthcare Worker
Data is reviewed annually and verified by ID
Driver License/ID
*
Upload Driver License/ID
Ensure the photo is well-lighted and clear. We will contact you to submit again or bring documents to clinic.
Insurance Types
Select all that apply
Are you the principle member of this insurance policy?
Yes
No
First and Last Name of Principle Member
Principle Member Date of Birth
Insurance Card - If you do not use insurance, you may leave this blank.
Upload Insurance Cards (front and back)
Ensure the photo is well-lighted and clear. We will contact you to submit again or bring documents to clinic.
Secondary Insurance Card
Are you the principle member of this insurance policy?
Yes
No
First and Last Name of Principle Member
Principle Member Date of Birth
Pharmacy Benefit Card
Insurance Comments
Did you upload the front AND back of all insurance and pharmacy cards?
"Yes, I uploaded images of the front and back."
Claims processors require the information contained on both sides of the card, even if it doesn't contain member benefit information.
Upload Photo
Show your best self
Upload a clear photo. If the photo is missing or low quality, we will use the photo from your ID instead.
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