GIVE THE GIFT OF TELE-MEDICINE

YOUR LOVED ONCE WILL APPRECIATE THE GIFT

Granting the gift of simple, timely, and no-cost access to quality healthcare to someone in need is a wonderful and thoughtful gift.

Please simply complete the gifting form below, and we take care of the rest.

TYPE OF GIFT(Required)

DESIRED GIFT(Required)

YOUR INFORMATION

FULL NAME(Required)

First Last

MAILING ADDRESS(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

YOUR EMAIL ADDRESS

MOBILE PHONE

PAYMENT DETAILS

PREFERRED PAYMENT METHOD(Required)

PLEASE LET US KNOW HOW YOU WOULD LIKE TO PAY FOR YOUR PROGRAM MEMBERSHIP

CARD NUMBER(Required)

EXP. MONTH(Required)

EXP. YEAR(Required)

CVV CODE(Required)

PAYPAL ID(Required)

We will send a payment request to your PAYPAL ID shortly. Please complete the payment request once you received it.

We will send an electronic invoice with a payment link to your provided email address shortly. Please complete the payment request once you received it.

We will send you a link to your email address with a link where you can complete the authorization of your membership fees.

Your Membership activation will be processed once we have received your payment.

You will received an email and a text message with usage instructions, within 24 - 48 hours of payment receipt.

WHO WILL RECEIVE YOUR GIFT?

RECIPIENT NAME(Required)

First Last

RECIPIENT MAILING ADDRESS(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

MOBILE PHONE(Required)

HOME PHONE

THEIR EMAIL ADDRESS(Required)

GENDER

BIRTHDATE

MESSAGE FOR THE RECIPIENT

PLEASE WRITE A PERSONALIZED MESSAGE FROM YOUR TO THE RECIPIENT OF YOUR GIFT. WE WILL DELIVER THIS MESSAGE TO THE GIFT RECIPIENT WITH THEIR ACCOUNT INFORMATION.