HRGI New Patient Enrollment Form

HRGI NEW ENROLLMENT

MONTHLY COVID-19 HOME KITS
Name

First NameLast Name
Date of Birth

MonthDayYear
E-mail
example@example.com
Assigned Gender at birth
Contact Number:
By Checking this box and entering your phone number above, you consent to receive marketing text messages and order updates from Divine concepts on be half of your doctor at the number provided, including messages sent by constant contact. Consent is not a condition of any purchase. Message and data rates may apply. Message frequency varies. You can unsubscribe at any time.*

YesNo
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
INSURANCE INFORMATION

MEDICAREMEDICAIDPPOHMO MANAGED CARE PLAN
INSURANCE COMPANY NAME
POLICY NUMBER (THIS IS ON YOUR CARD AND CAN START WITH LETTERS)*
POLICY GROUP #
Upload a copy of your insurance card front and back

Cancelof
Consent*

By clicking here you are consenting to our privacy policies, monthly subscription billing to your insurance during this program, and monthly shipping of covid-19 self test kits to your home. For more details visit our website www.divineconcepts.co.
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HRGI NEW ENROLLMENT