Patient Intake Form

We're so excited for you to join us. Let's start by getting some more information about you.
What's the main reason why you're interested in participating in BreatheSuite's program?*

Reduce shortness of breathBuild strength for daily tasksImprove confidence with movementManage symptoms proactivelySleep better and feel restedReduce anxiety

We have great news for you.

90% of patients that have {whatIs} have reported that they are able to {whatsThe9} in 12 weeks with BreatheSuite.

Now let's get your information so we can get you started
Name*

First NameLast Name
Email*
Phone Number*
Format: (000) 000-0000.
Date of Birth*

MonthDayYear
Date
State of Residence*
Your privacy and data security are our top priorities. All information submitted is handled in accordance with HIPAA guidelines and our privacy policies. For more details, please review our HIPAA & Privacy Policies.

Great news! BreatheSuite is available in your area.

Our insurance verification team will verify your insurance benefits to determine eligibility for BreatheSuite.
Insurance Carrier*
Insurance Plan Name*
Insurance Plan Type
Policy Number/Member ID
Great news! BreatheSuite is available in your area. Let's get you started on next steps!
Unfortunately, BreatheSuite is not currently available in your area. We are working diligently to bring this to you.
Who is your doctor?*
If you have a pulmonary doctor, list their full name. Otherwise, list your primary care doctor.
My doctor is a *

What is your preferred method of contact?
This is how we will initially reach out to you to let you know of your program enrollment status. Please select the option that works best for you.

Got it. We'll contact you initially via email. If we don't get an immediate response, we'll also try to phone/text you.

The email we have for you on file now is {email}.

If this is not correct, go back and change the email that you used in this form.
Got it. We'll contact you initially via text. If we don't get a response, we'll also try to phone/email you.

The phone we have for you on file now is {phoneNumber}.

If this is not correct, go back and change the number that you used in this form.
Got it. We'll contact you initially via phone. If we don't get a response, we'll also try to text/email you.

The phone we have for you on file now is {phoneNumber}.

If this is not correct, go back and change the number that you used in this form.

We're so excited for you to join us. Let's start by getting some more information about you.