Premier Custom Health Solutions

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Welcome to PCHS where we are introducing the internet to one on one personalized healthcare.

First Name *

Last Name *

Date of Birth *

YYYY

State of residency *

Streat Address

City *

Zip *

Identification type *

ID # ( letters/ numbers on govn't issued ID ) *

What is your email address?

Contact Number

Preferred method of contact *

Telephone

Text ( preferred )

What is the reason for your medical consultation?

Emergency Contact Name?

Active Medications. * use N/A if not taking any medications *

Allergies *

Are you Sick ?

Yes

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Area of Concern *

ED ( erectile dysfunction )

COVID **FLCCC** testing / treatment / prevention

HRT ( bio-identical hormone replacement treatment )

ANTI-AGING

Required

Free Visit for Uninsured

This is a separate program for uninsured only. The approval process is aprox. 24-48hrs which upon approval you then will get a temp ID number and your visit will be scheduled. If you do not qualify for this the visit will be $200. This does not include any cost of medication that the doctor may prescribe.

To apply for the free covid visit please confirm you do not have any health insurance of any kind including Medicaid or Medicare. *

I confirm, I do NOT have any type of healthy coverage including Medicaid or Medicare.

I have insurance but understand we don't not take insurance so it will out of pocket cost associated with the visit.

Cash pay $200 ( we do not take any type of insurance )

Cash Pay

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