Single User – My Smarter Care

My Smarter Care Registration

Single User Form

Name(Required)

First Middle Last

Address(Required)

Street Address City State ZIP Code

Phone Text Message Capable(Required)

Two users cannot share the same text message capable phone number. Enter a unique phone number for each user.

Email(Required)

Enter Email Confirm Email

Preferred Language(Required)

Age(Required)

Please enter a number from 15 to 99.

Biological Sex(Required)

Pregnancy(Required)

Do you smoke?(Required)

Would you like to recieve Behavioral Health Support?(Required)

Are You Diabetic(Required)

Are you undergoing Cardiac Care?(Required)

Do you have High Blood Pressure(Required)

Are you over weight?(Required)

Are you struggling with Substance Abuse?(Required)

Current Health Insurance Provider(Required)