New Patient/Member Form

 

Two Ways to Register:

 

OPTION 1: REGISTER BY PHONE

 

New patient welcome (No Blocked Calls will be accepted). We will be happy to answer any question regarding placing an order or information. Must be 18 yrs of age or older.

 

1. Call 714-955-9712 with Name, DOB, current address, phone number, Dr.’s name, phone number, Patient ID # and exp. date of recommendation; 2. Wait for verification call back; 3. Have order ready when you receive call back.

 

Please print and sign the "New Member/Paitent Form". If you do not have a printer, our dirvier will provide the form for you.

 

Please have your Dr.’s recommendation ready for driver on your first delivery.

 

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OPTION 2: Fill out the on-line registration form below then click the "Submit" button to send us the form. Call us to verify that we received your registration. ***Fields marked with an asterisk (*) are required***

 

* First Name

 

* Last Name

 

Username

 

(you will use this to login to the member's area)

 

Password

 

* Date of Birth ( xx-xx-xxxx)

 

* Address

 

* City/ State/ Zip

 

* Phone Number

 

Alternate Phone Number

 

* Patient ID

 

* Expiration Date

 

* Email Address

 

PHYSICIAN INFOMATION

 

* Name of Doctor

 

* Phone Number

 

* Condition which qualifies:

 

* How did you hear about us?

 

Questions or Comments:

 

* I certify I am over 18 years old.