Two Users My Smarter Care Registration 2 TWO User Form Step 1 of 2 50% User 1(Required) First Middle Last Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code User 1 Phone Text Message Capable(Required)Two users cannot share the same text message capable phone number. Enter a unique phone number for each user.User 1 Email(Required) Enter Email Confirm Email Two users cannot share the same email. Enter a unique phone number for each user.User 1 Age(Required)Please enter a number from 15 to 99.User 1 Biological Sex(Required)FemaleMaleIn TransitionUser 1 Preferred Language(Required)EnglishSpanishUser 1 Pregnancy(Required)Not ApplicableTrying to Concieve NowI am in my First TrimesterI am in My Second TrimesterI am in my Third TrimesterI am Due Any DayUser 1 do you smoke?(Required)YesNoUser 1 would you like to recieve Behavioral Health Support(Required)YesNoUser 1 Are You Diabetic(Required)YesNoUser 1 are you undergoing Cardiac Care?(Required)YesNoUser 1 do you have High Blood Pressure(Required)YesNoUser 1 are you over weight?(Required)YesNoUser 1 are you struggling with Substance Abuse?(Required)YesNoUser 1 Current Health Insurance Provider(Required)AetnaBlue Cross Blue ShieldCignaHumanaPHCSUnited HealthcareUMPCNoneUser 1 Consent(Required) I Agree to the Terms, Conditions, and End License User AgreementI accept the Terms, Conditions, and End User License Agreement as posted on this website. I understand My Smarter Care will be sending me emails, test (SMS) messages, and HIPAA compliant chat messages. I understand for My Smarter Care to empower me, to take control of my health, accepting emails and messaging is essential. User 2User 2(Required) First Middle Last User 2 Phone Text Message Capable(Required)Two users cannot share the same text message capable phone number. Enter a unique phone number for each user.User 2 Email(Required) Enter Email Confirm Email Two users cannot share the same email. Enter a unique phone number for each user.User 2 Preferred Language(Required)EnglishSpanishUser 2 Age(Required)Please enter a number from 15 to 99.User 2 Biological Sex(Required)FemaleMaleIn TransitionUser 2 Pregnancy(Required)Not ApplicableTrying to Concieve NowI am in my First TrimesterI am in My Second TrimesterI am in my Third TrimesterI am Due Any DayUser 2 do you smoke?(Required)YesNoUser 2 would you like to recieve Behavioral Health Support(Required)YesNoUser 2 are you undergoing Cardiac Care?(Required)YesNoUser 2 Are You Diabetic(Required)YesNoUser 2 do you have High Blood Pressure(Required)YesNoUser 2 are you over weight?(Required)YesNoUser 2 are you struggling with Substance Abuse?(Required)YesNoUser 2 Current Health Insurance Provider(Required)AetnaBlue Cross Blue ShieldCignaHumanaPHCSUnited HealthcareUMPCNoneUser 2 Consent(Required) I Agree to the Terms, Conditions, and End License User AgreementI accept the Terms, Conditions, and End User License Agreement as posted on this website. I understand My Smarter Care will be sending me emails, test (SMS) messages, and HIPAA compliant chat messages. I understand for My Smarter Care to empower me, to take control of my health, accepting emails and messaging is essential.
