If you're applying for a Couple or Family Plan, please use this link to add additional members — [Click here].

First Name *

Last Name *

Date of birth *

Gender *

Phone *

Email *

Street Address *

City *

State *

Country *

Postal code *

Membership Type *

Individual $85

Couple $160

Family $200

If you are enrolling in a Couple or Family Plan, please refer to the link at the top of this form to add additional member details.

Appointment Preferences

How would you prefer to meet your provider? *

In-person at our Cincinnati Office

Telehealth (Virtual Visit)

Preferred Date/time for appointment *

Note: We will send you an email once your preferred date and time has been confirmed by our provider.

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.