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YOUR CART
The Chiron Healing Collective
Our Mission
“Our mission is to expand holistic healthcare to individuals in underserved income populations, healthcare workers and emergency service providers to aid in the collective healing and wellbeing of the Individual and community.
Patient Application
Please choose ONLY ONE selection type from ONLY ONE category served:
#1-Emergency Services/First Responder
or
#2-Healthcare Service Employee
or
#3-Underserved/Low Income and leave the other numbers blank:
1.
Emergency Services/First Responder:
Choose One
*
Fire Service
Police
Sherriff
Military
Veteran
Other
If "Other", please specify.
*
Please continue to section #4
2.
Healthcare Service Employee:
Where are you employed?
*
Please continue to section #4
3. Underserved/Low Income:
Choose One
*
Unemployed
Disability
Fixed Income
Other
If "Other", please specify.
*
Where are / were you employed?
*
Please state your annual household income.
*
*Please bring verification of income for acceptance for low income.
For example: Tax return final income page.
Family Size.
*
#4 Complete Your Information
*
Indicates required field
Name
*
First
Last
Email
*
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Date (MM/DD/YYYY):
*
Choose Any
*
I Agree to Sign This Patient Application Electronically.
Type in your FULL NAME to serve as your Electronic Signature:
*
How did you hear about us/who referred you?
*
Submit
Printable Patient Application
