Application to AJ Primary Health Care

- Step 1 of 4

Full Name *

First

Last

Date of Birth (MM/DD/AAAA) *

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Email

Email

Confirm Email

Phone *

Captcha *

=

Next

Do you declare you have reviewed and understood all the content exposed in "AJ Primary Health Care" Agreement, Coverage, Laboratory Tests and Radiology Services? *

• YES, and I agree.

Next

Product: AJ Primary Health Care *

Price: $ 75.00

Initial payment ($40 application fee + $35 first month of services)

I understand that I have to show my proof of payment on my first appointment

• YES, and I agree

Next

Do you authorize Javier Garcia DNP Medical Office to contact you by email and/or telephone provided in this application if necessary due to difficulties with your application, initial payment or medical appointment? *

• Yes, I agree.

Signature *

First and Last Name

Phone

Submit

AJ Primary Health Care

2020