Please, enter your first name followed by last name
Please, give the name of your Preferred pharmacy and its phone number
Please, enter your cell phone
If this cell phone is the best way to reach you, please check this box. If not, provide an alternate phone
Please, provide your email <br/>
Please, re-enter your email
Please, enter your complete address including your street address, city, state and zip code.
Individual to contact, in case of emergency
Indicate your relationship to emergency contact
Best phone to reach the Emergency Contact
I understand that this will divulge my medical condition and other personal medical information to other group member(s). I agree to keep all information that is shared in the group by other member(s) confidential and to not discuss such information outside of the group. I understand that I don?t have to share any personal information with the group or health care providers unless I choose to do so.
Only if you selected yes on the above field then typing your name in this field will be equivalent to signing your name on a paper document and will indicate your consent to participate in group visits/sessions.
Financial Policy and other General Policies
I hereby acknowledge that I have reviewed and agree with the Financial Policy and other General Policies of this practice available on the website at lifestyledocs.com. I authorize Embee Lifestyle Docs, PLLC to charge my credit card for the various services as outlined on the Financial Policy.
Typing your name in this field will be equivalent to signing your name on a paper document. Please, sign in this field only after reviewing the Financial Policy and other General Policies document.