PAC Benefits Claim Form
*benefits brought to you by VMD will activate within 72 hours of submission
PLEASE SPECIFY FOR BENEFITS:
*
PAC NFT TOKEN ID
*
WHICH BENEFITS WOULD YOU LIKE TO CLAIM? (CHOOSE ONE)
*
Name
*
First Name
Last Name
Email
*
example@example.com
US MEMBERS CLAIMING TELADOC MEDICAL BENEFITS
MUST COMPLETE INFO BELOW
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
/
Month
/
Day
Year
Date
Phone Number
-
Area Code
Phone Number
Submit Form
Should be Empty: