Eligibility Quiz Form This form should be used for any new patients who want to assess their eligibility for alternative medicines. 1Eligibility Information2Personal Information FacebookThis field is for validation purposes and should be left unchanged.Are you over 18 years old?(Required) Yes No Do you suffer from a chronic medical condition that has been ongoing for more than 3 months?(Required) Yes No Have you tried other conventional treatments for your condition without success or experienced significant side effects?(Required)You may not be eligible for a treatment plan with Mediflora if you have not tried other conventional treatments. Yes No Name(Required)Must match your Medicare card First Name Last name Email(Required) Phone number(Required)Date of Birth(Required)You must be over 18 DD slash MM slash YYYY We would like to contact you for a dicussion about how we can potentially support your condition(Required) I agree to receive other communications from Mediflora Organic Health. You can unsubscribe from these communications at any time. For more information on how to unsubscribe, our privacy practices, and how we are committed to protecting and respecting your privacy, please review our Privacy Policy. By clicking book an appointment below, you consent to allow Mediflora Organic Health to store and process the personal information submitted above to provide you the services requested.
