(Jan 2025) Member Jotform 1

Welcome to Elektra!

We're SO excited to welcome you into our community of badass women smashing the menopause taboo. Let's start with a few questions to set up your account.
Name*

First NameLast Name
Email*
By entering your email, you agree to receive marketing communications from Elektra Health.
Phone Number*
Format: (000) 000-0000.
Date of birth*

MonthDayYear
Knowing your age is helpful to understand what phase of menopause you might be in.
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your 12-month Elektra membership is sponsored by Mass General Brigham Health Plan!
Please share your insurance information so we can verify your eligibility.
YesNo
Policy holder name*

First NameLast Name
Policy holder date of birth*

MonthDayYear
Date
Member ID / Policy Number*
Group number
Photo upload: front of insurance card

Cancelof
Photo upload: back of insurance card

Cancelof
Now that the basics are out of the way, click below to move on to our 3 minute hormonal health questionnaire.
Group
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UTM_campaign
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Should be Empty:

Welcome to Elektra!