First Name *

Last Name *

Address

Street Address

City

State

Country *

Postal code

Phone *

Email *

Do you have a PCM (patient care manager) or primacy care physician? *

Yes

I have one or the other, or both

Please select all that apply

Have you consulted with your PCP or PCM prior to requesting our services? *

Yes

If you selected no, please explain why (optional)

Not answering this question will not affect your ability to receive service. It does however, help us understand your circumstances to provide you with the best service to accommodate your needs.

Is this consultation for an individual under the age of 18? *

Yes

What health organization are you affiliated, associated, or employed with? *

Type N/A if this does not apply

Do you have insurance coverage? *

Please provide your insurance provider *

Please provide us with a professional high resolution photograph (optional)

By checking this box, I confirm that I have read, understood, and agree to the Terms of Service and Privacy Policy of Different Reasons Inc. I acknowledge that my use of the services is subject to these terms, and I accept any legal obligations outlined within. I also consent to the collection and use of my data as described in the Privacy Policy.