Please fill out the form to create your user account. Note that all your information will be encrypted, secure and remain confidential.

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Basic Info

First Name

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Last Name

Date of Birth (mm/dd/yyyy)

Password

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Personal

Country you are currently located in

For which state do you want a doctor evaluation

Please provide the exact address where you would like to receive your recommendation card.

Address

Apartment

City

Country

State

Postal Code

Phone

Gender

Medical

What is/are the main medical problem(s) which you currently have or have had in the past?*:

HIV/AIDSNauseaFibromyalgiaSeizuresArthritisMuscle SpasmMigraine HeadachesAnxietyChronic PainGlaucomaCancerTrouble SleepingLoss of AppetiteWeight LossOther

Are you RENEWING your recommendation (Have you had a recommendation in the last 10 years)*:

Do you currently use specific medications for your medical condition?:

Are you taking any prescription medications or herbs? *:

Do you have any allergies to any medications? *:

Have you ever had any surgeries or been hospitalized?:

Do you exercise?:

Do you smoke tobacco?:

Do you drink alcohol?:

Are there health/medical problems that occur frequently in your family?:

Have you experienced or been diagnosed with any of the following *:

DepressionBipolar DisorderSchizophreniaSuicidal thoughtsADHDNone

Are you pregnant? *:

Breastfeeding?:

Do you have a primary care provider? *:

When was the last time you saw your doctor/specialist about these complaints? (mm/dd/yyyy)

Medical Files

If available, you will have an ability to upload to your portal previous Recommendation or any other medical records as related to the medical condition(s) identified above.

I cannot provide the records because of:

Provide details on the medical condition and diagnosis:

Payments

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Fee charged after visit:

Please fill in your payment information. You will be charged only after your appointment is successfully completed. Please note that in order to protect your privacy the credit card line item will only state Heally Inc.

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