DirectShifts - Individual Sign-Ups

Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.

Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Language*
Date of Birth*

MonthDayYear
Age restrictions apply: Primary account holder must be 18-64 years old.

Payment / Billing Details

Plan Selection*

Vitable Primary Care - DirectShifts Membership

Get access to delightful virtual and in-home primary care along with mental health, free prescriptions, labs, annual wellness visits, and more. $0 copays and no deductibles to access primary care. Family members and dependents are covered for free. Your subscription will take up to Five Days to activate.

Free for the first Five Days then, $50.00 for each month

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

My billing address is the same as my home address
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Payment / Billing Details