Secure Online Enrollment

Member Information
First Name:*
Last Name:*
Street Address:*
Apt/Suite/Unit:
City:*
State:*
States that are omitted from the selection box do not have access to the benefits provided in this package.*
Zip Code:*
Primary Phone Number:*
- -
Email Address:*
Confirm Email Address:*
Your email address will be used for customer support and important program communications only. We will not market to this email address or share with any third parties.
Billing Information
Card Type:*
Card Number:*
Name on Card:*
Security Code:*
What's this?
Expiration Date:*
My billing address is the same as my membership address.

Street Address:*
Apt/Suite/Unit:
City:*
State:*
States that are omitted from the selection box do not have access to the benefits provided in this package.*
Zip Code:*

I AGREE

I authorize MyDoctorHero to deliver the products and services I have ordered today. I have read the disclosures below. I understand that my credit card will be billed $29.95 today, and $29.95 each hereafter unless I call to cancel.

If you are not completely satisfied with your membership, you have the right to cancel within 30 days from the date you received your membership material and receive a refund for your membership.
I also acknowledge that I agree to abide by the Terms of Service governing this program.
I have read the Consent to Telehealth Disclosures and agree to the terms of use described in order to be consulted by a telehealth provider.
*Package not available in GU,VI.

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