Thrivability Eligibility

1
Thrivability™ is a registered 501(c)(3) wellness charity offering nutrient-rich intramuscular (IM) injections (B12 shots + others) on a sliding scale to those who are eligible. Our shots are formulated with vitamins, minerals, antioxidants, amino acids + homeopathic medicines for wellness, prevention of illness + to facilitate healing for both acute + chronic conditions. We believe everyone deserves access to this wonderful service + that nothing should be a barrier to experiencing the healing power of this treatment modality. We want everyone to be healthy + to thrive!

Please take a few moments to complete this short eligibility form. Depending on your responses, we may need documentation for verification purposes; namely, for household income (if you're claiming less than 250% of the current U.S. poverty level) + proper ID if you're a first responder.

Thank you!
Press
Enter
2
Name* This field is required
First Name
Last Name
Press
Enter
3
Please choose one of the following reasons why you are seeking status as a client with Thrivability™ for nutrient injection therapy.* This field is required
LOW INCOME (unemployed, fixed income)
SEVERE MEDICAL DISABILITY (disabled; inability to work)
FIRST RESPONDER/MILITARY (police officer, firefighter, active military, veteran, EMT, paramedic)
DEVOUT VEGAN (those who don't eat or use animal products including honey, milk, eggs, wool, leather, etc.)
PRIMARY CAREGIVER of a first degree relative with a severe medical disability or in a hospice program
Press
Enter
4
Please select one of the following to explain your low income status.* This field is required
Unemployed
Disabled
Fixed Income
Other
Press
Enter
5
Please explain your answer "other."* This field is required
Press
Enter
6
What is your diagnosis.* This field is required
Press
Enter
7
What is your family member's diagnosis? How are you related?* This field is requiredYou must be the primary caregiver of a family member who is medically disabled.
Small
Normal
Large
Huge
Ok
Ok
Press
Enter
8
Please select one of the following.* This field is requiredPlease present your badge or ID for verification.
Police Officer
Firefighter
Active Military
Veteran
Paramedic / EMT
Press
Enter
9
Please state your annual (yearly) household income.* This field is requiredThis is the combined income for one year of all adults sharing a residence.*
*This includes spouse, roommates, parents, children, etc.
Press
Enter
10
How many people are in your household?* This field is requiredInclude all adults and children living at your place of residence.
Press
Enter
11
Contact InformationPlease provide us with your email address so we may contact you should we need to clarify anything with your enrollment or eligibility.
example@example.com
Press
Enter
12
You agree that all your answers are true to the best of your knowledge. If you're approved for the THRIVABILITY program, you'll need to complete and e-sign a separate Consent Form prior to receiving treatment if you have not done so already.* This field is requiredPlease sign and click submit.
Clear
Press
Enter
13
Tags
[object Object]
Press
Enter
Should be Empty: