Patient/Client Member Form

Name

First NameLast Name
E-mail
Phone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Birth Date:

MonthDayYear
Gender

MaleFemale
Where did you hear about us?

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Member Rules
I have read, understood, and accepted the rules for membership.
MEMBERSHIP RULES
1. You must be 18 years of age or older.to be a member.
2. You promise NOT to use inappropriate or threatening language online or your membership may be revoked. You also promise not to conduct any fraudulent activity or misrepresent yoruself online, or have more than one active Member Account at a time.
3. You will not sell or market products to clients or patients through Healthmagus's website or patient portal unless explicitly approved, affiliated or in collaboration with Healthmagus.
Privacy Policy
I have read, understood, and accepted the PRIVACY POLICY for membership.
Once you submit your application, you will recieve and email confirming your membership and how to get started. Please contact a Helathmagus health coordinator at anytime if you have questions.

Thank you!
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Member Rules