Good Faith Remote Care

First Name *

Last Name *

Date of birth *

Address

Street Address

City

State

Country

Postal code

Phone *

Email *

Best Contact Method *

Text

Call

If Patient is Under 18 year of age, please enter Guardian Contact info:

Guardian Name

Guardian Date of Birth

Guardian Phone

Emergency Contact Info:

Emergency Contact *

Relationship to Patient *

Emergency Contact Phone Number *

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

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Together, we heal. Let that journey begin with Good Faith.

Contact us:

[email protected]

Good Faith Health does not provide crisis or emergency services, please dial 911 or contact local emergency services if you are experiencing an emergency.