Patient Application

Name:*

First Name: Last Name:

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Email*

example@example.com

Referring Practitioner Code

Code provided by Practitioner

Acknowledgements:*

By entering my information and using the site, I agree to the Privacy Policy and Terms of Use.I understand that by entering my information and clicking “Register” below, I am authorizing Alight Health Inc. to share my name, email address, and order history on an ongoing basis with the practitioner identified by the link above who may contact me at that address for consultation or about other products or services. For information about Alight Health Inc.’s privacy practices, I may visit Alight Health Inc.’s Privacy Policy. For information about my healthcare practitioner’s privacy practices, I will contact my practitioner directly.

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