Additional Information

We’d Love to Get to Know You Just a Little Better!

Hello there! You recently signed up for our pre-launch waitlist!

We'd like to get to know you better so we can personalize our services for you. If you could please provide the information below, we'd really appreciate it!

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Your Contact Details - correct as needed

Name*

General Information (fields with * are required)

Age Range*
What age range do you fall into?
Gender*
Please select your gender

Healthcare Options (fields with * are required)

Healthcare Coverage*
Choose the option that best describes you
Care Options*
How do you typically get medical care for minor illnesses?
Access to Healthcare*
Which of these statements best describes your situation?
ChatRx Usage*
Are you primarily interested in ChatRx for:
Common Conditions*
For which conditions would you use ChatRx?
How did you hear about ChatRx? **
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Which devices would use to access ChatRx?
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How would you like to receive updates? **
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Optional Information

The information below is optional but will help us customize your experience even more.
Education
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Income Bracket
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Please enter your primary zip code
This field is for validation purposes and should be left unchanged.