Basic Intake Information
By providing your phone number, you agree to receive SMS Account Notifications, emails, and calls from the Care Sync LLC platform. All correspondence will be related to the completion of a telehealth encounter or system patient account notifications. Message frequency may vary. Standard Message and Data Rates may apply. Reply STOP to opt out. Reply HELP for help. We will not share mobile information with third parties for promotional or marketing purposes.
*
Name
*
First Name
Last Name
DOB
*
-
Month
-
Day
Year
Date
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Submit
Should be Empty: