2c FHCi Patron HPx Program Registration

HPx Program Registration

One Form per HPx Program Registrant
I acknowledge that I am registering for an HPx Program and I have already consented to research through my FHCi Patron agreement.

By registering for this HPx Program, it will become active in my Patron Portal and be accessible to me, my HPx Practitioner and the research analysis team.

The data entered and all Personal Health Information (PHI) is held in confidence, in a private and secure data base system.
Date

MonthDayYear
Date
FHCi HPx Supervisor/Practitioner's Name*

First NameLast Name
Practitioner File Number*
Your FHCi HPx Practitioner's Email*
example@example.com
Registrant Name*

First NameLast Name
Email*
example@example.com
FHCi Patron File Number*
FHCi HPx Programs:*
prevnext( X )
1. Healthy Biome HPx ProgramAll ages; 9 weeks
$15.00 Quantity



2. Full Childhood Immunological HPx ProgramPay for only 1 per family; infant to 18yers of age; 50 months
$15.00 Quantity



3. Young Adult and College Prep HPx Program17-25 years of age; 6 or 12 months
$15.00 Quantity



4. Travel HPx ProgramAll ages; 5-15 weeks
$15.00 Quantity



5. Healthy Sexuality and Pre-Procreation HPx ProgramAges 16-35; 7 or 14 months
$15.00 Quantity



6. Healthy Pregnancy and Fetal Development HPx ProgramBefore conception through pregnancy; 7 months
$15.00 Quantity



7. Immune Health for Elders HPx Program55 years and older; 6 months
$15.00 Quantity



8. Single disease prevention/treatment with HPxAll ages; 2-5 weeks. Choose this for current disease outbreaks
$15.00 Quantity



Total

$0.00
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