Step 1 of 5

Start your intake

Fill out your information below. The physician will contact you by text or phone to verify it before your visit.

What you'll need

  • • Full name
  • • Date of birth
  • • State of residence (New York or Connecticut)
  • • Phone number
  • • Email address
  • • Your condition / relevant medical information
  • • Government-issued photo ID (CT patients may also need proof of residency)
✓ 100% refund if you don't qualify for certification.

Intake form

TODO — Site Owner Embed the HIPAA-compliant intake form here (vendor with a signed Business Associate Agreement). This placeholder collects no data. Replace this box with the vendor's embed code or a link/redirect to their hosted form once selected.

Optional: pay now

You can pay upfront to streamline scheduling, or wait until after your information is verified.

Opens Stripe's secure checkout in a new tab. Payment is kept separate from your health information.

TODO — Site Owner These buttons are wired to js/stripe-config.js. Replace the placeholder URLs there with your real Stripe Payment Links (with "Allow promotion codes" enabled) and the buttons will go live automatically — no HTML changes needed.

What happens next

2

We verify

The physician contacts you by text or call to confirm your information.

3

Payment

If you haven't already paid, you'll get a secure Stripe payment link.

4

Your visit

A phone or message-based evaluation — video if needed.

5

Certified

NY: emailed & registered automatically. CT: state emails you to complete registration.