First Name *

Last Name *

Phone

What age range do you fall into? *Please select one option

Your Gender *

Male

Female

Prefer not to say

Please select your gender

Choose the option that best describes you *

I have health insurance with a low deductible

I have health insurance with a high deductible

I'm currently uninsured

I'm covered by Medicare

I'm covered by Medicaid

Direct primary care or concierge medicine

Prefer not to say

Please select one option

How do you typically get medical care for minor illnesses? *Please select one or more

Which of these statements best describes your situation? *

I live in an area with plenty of healthcare options

I have limited healthcare options nearby

I have to travel 30+ minutes to reach medical care

I have difficulty accessing care due to my work schedule

I move frequently (college student, gig worker, digital nomad)

Please select one option

Are you primarily interested in ChatRx for *

Myself

My entire family

Children and/or parents

Someone else

Please select one or more

For which conditions would you use ChatRx? *Please select one or more

Which devices would use to access ChatRx?

Smartphone

Tablet

Desktop computer

Laptop computer

Please select one or more

How would you like to receive updates? *Please select one or more