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It’s easy to become a Healsa Patient:

First, enter your contact information and choose your Healsa Physician.
Sign up for our Preferred Family Plan and receive significant discounts for each additional family member.
Review and accept the Terms of Agreement and select the payment option that is right for you.
Once you choose your payment option, your discounts will be applied and your total will be calculated before you enter your method of payment.
After you enter your payment information on our secure site, you’re on your way to “having a doctor in the family”.
Any questions? Need assistance? Please call us at 1.888.9HEALSA (1.888.943.2572) and a Healsa patient specialist will be more than happy to assist you.

Submitted by jryan on Wed, 07/13/2011 - 21:02

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Your Name: *

DOB: *

Your Doctor: *

Are you pregnant:

Yes

Your E-mail Address: *

Single Parent?:

Yes

Spouse Name (if joining):

DOB:

Spouse's doctor:

Is your spouse pregnant:

Yes

Spouse's E-mail Address (if joining):

Street Address: *

City: *

State: *

Zip: *

Home Phone:

Cell:

Spouse's Cell:

Additional Family Members Enrolling: *

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

Name:

DOB:

Phone (if different):

Email:

Doctor (please choose one):

Is this family member pregnant:

Yes

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