Patient Application

1

What is your name?* This field is required.

First Name

Last Name

2

What is your email address?* This field is required.

example@example.com

3

What is the Referral CODE provided to you by your Practitioner?* This field is required.

4

Acknowledgements:* This field is required.

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.