Please answer the questions as best as you can to begin your sign-up
This will take you 5 - 7 minutes
What is your name?
*
First Name
Last Name
What is your address?
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your email address?
*
example@example.com
What is your phone number?
*
Please enter the best number where you can be reached
Can we send you information through text?
Yes
No
How old are you?
*
Under 18
18 - 24
25 - 34
35 - 44
45 - 54
55 - 64
Above 64
Do you have a personal doctor or health care provider? (PCP, Family doctor, Primary care doctor, etc.)?
*
Yes
No
What is your personal doctor or health care provider's name?
First Name
Last Name
Would you like for us to connect you to a primary care doctor?
Yes
No
Do you have active health insurance?
*
Yes
No
What type of insurance do you have? (select all that apply)
*
Medicare
Medicare Advantage
Medicare Supplement
Medicaid
Commercial (Blue Cross, Humana, UnitedHealth Care, etc.)
Other
How did you hear about Hight Health?
*
Facebook
Instagram
Forest Park Minister's Association
Hight Health Website
Health Fair Flyer
Attended a Hight Health Event
Other (For example, your church.)
Are you interested in talking about the health needs in your area?
*
Yes
No
Other
Please verify that you are human
*
Submit
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