National Association of Affordable Health Care




REGISTER NOW


1. DOWNLOAD AND
FILL OUT OUR FORMS
(ALL 3 REQUIRED)
Payment Form
HIPAA Form
Registration Form


2. FAX IN FORMS, RECENT MEDICAL RECORDS, AND A CURRENT ID


3. CONTACT US TO SCHEDULE YOUR APPOINTMENT


1 954 762 7971


Note: Part 1 and 2 of this
process must be fully complete before an appointment with a
doctor can be scheduled.



Registration Form

Patient’s Name
Date of Birth
Age
Sex
Nationality
Weight (kilograms)
Height(cms)
Blood Group
Address
Telephone
Email
Present medical illness
Family health history
History of allergy
Allergy to medication No Yes
If yes to above question, then Specify
Health History
Do you have Allergies or reactions: (for example, food, medication, latex, or other) No Yes
Do you have Hay fever, asthma, or wheezing No Yes
Do you have Eczema or frequent skin rashes No Yes
Do you have Convulsions/Seizures No Yes
Do you have Heart trouble No Yes
Do you have Diabetes No Yes
Do you suffer from Frequent colds, sore throats, ear aches (4 or more per year) No Yes
Any Additional Information


Registration Process

Register now to set up your doctor appointment!

Prices on treatment will vary depending on the severity of each of your conditions, the doctors diagnosis for treatment, and which fulfillment program that you may choose.

Once you have completed the Registration Form (on left) you
will need to fax us your medical records, current ID, the Payment Form, and HIPAA Form

Once you have submitted all the necessary paperwork please call our office at 1 954 762 7971

Appointments will not be set up until all of the required documents are sent to us.

Our friendly customer service staff is standing by waiting to service you.
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