Discount Application Form
Answers are strictly confidential and will only be used to determine eligibility and discount percentage. All records are permanently deleted after review by the clinic director.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Name
*
First Name
Last Name
Email
*
example@example.com
City of Residence
*
I am a (check all that apply):
*
Honorably Discharged Veteran (U.S. or Allied Military)
Combat Veteran
Disabled Veteran
100% Disabled Veteran
Retired First Responder
Status
*
Single
Married
Long-term partner
Children
*
No minor children
Minor children living at home
Primary residence is:
*
Rented
Owned
Please upload proof of your pension, retirement, military service (DD214 to qualify for all eligible discounts) or any other documentation you'd like considered.
*
Browse Files
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(Please REDACT any sensitive information such as SSN.)
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of
I hereby affirm that the answers provided in this application are complete, true, and accurate.
*
Submit
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