Patient/Client Member Form

Name

First Name Last Name
E-mail
Phone Number:

Area Code Phone Number
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Birth Date:

Month Day Year
Gender

Male Female
Where did you hear about us?

A Friend or colleauge Google Blog Post News Article
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