Q1. Please enter the following: First Name, Last Name
Q2. Please enter the following: Email Email:
Q3. R.E.A.L. will protect your information. Information is only used as is reasonably necessary to process your application or to provide you with health or counseling services which may require communication between HHSN and health care providers, medical product or service providers, pharmacies, insurance companies, and other providers necessary to verify your medical information is accurate and determine the type of medical supplies or health care services you need.
Q4. Phone Number:
Q5. Age:
Q6. Date of Birth MM/DD/YYYY:
Q7. Gender:
Q8. Do you have Health Insurance? Health Insurance IS NOT required, but if you have coverage we need to know.
Q9. If you answered "YES" above, please list: Health Insurance Company, Address, Policy Number, Phone Number:
Q10. Ethnicity
Q11. When did your symptoms begin MM/DD/YYYY?
Q12. Symptoms (check all that apply):
Q13. Other Symptoms / More information about Symptons