Application to AJ Primary Health Care Please enable JavaScript in your browser to complete this form. - Step 1 of 4Full Name *FirstLastDate of Birth (MM/DD/AAAA) *Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmailEmailConfirm EmailPhone *Captcha * = NextDo 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.NextProduct: AJ Primary Health Care *Price: $ 75.00Initial payment ($40 application fee + $35 first month of services)I understand that I have to show my proof of payment on my first appointmentYES, and I agreeNextDo 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 NameCommentSubmit AJ Primary Health Care 2020