Request An Appointment - Individual Plan
This form must be completed before we can schedule your appointment. Please complete all information as accurately as possible to ensure we can best meet your satisfaction.
- Currently, we do not provide services in the following states: Alaska, Hawaii, Louisiana, Massachusetts, Mississippi, North Carolina, Rhode Island, and South Dakota.
- Please note, we CANNOT prescribe narcotics, or controlled substances.
Notice: Currently, we cannot provide services in the following states: Alaska, Hawaii, Louisiana, Massachusetts, Mississippi, North Carolina, and South Dakota.
I acknowledge that the information above and attached is complete and accurate.
Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide Company instructions via Company's website or its affiliates, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and Company. You also represent that you are authorized to enter into this Agreement.