Member Form | Six Kind, Alexandria, VA

Member Information

Thank you for becoming a Six Kind member. Please fill out the form below in order to start your membership. Submissions are submitted securely.

You put your trust in us, and we take that responsibility seriously. Six Kind is the new standard in health care services.

First Name

Last Name

Phone

Street

Unit

City

State

Postal Code

Birthdate

Age

Nationality

Current Country of Residence

Employer

List All Medications, Vitamins and Supplements Taken, Including dosages and frequency.

List any Food, Drug or Environmental Allergies

List Any Surgeries, Including Approximate Dates

Neurologic

Seizures Head Injury, TBI or CTE TIA or Stroke

Pulmonary

Asthma Emphysema COPD TB

Renal

Kidney Stones Renal Failure Renal Insufficiency

Orthopedic

Broken or Injured Bone Back Injury Arthritis

Tobacco Use

Yes No Never

Tobacco Use Frequency

Alcohol Consumption?

Yes No

Alcohol Consumption?

Comments

Medical Insurance Card Upload (Front and Back)

Certification of Information

I certify that the information contained herein is complete and accurate to the best of my knowledge. I will inform my medical provider and Six Kind of ALL medical or health changes that occur after submitting this form. I understand that failure to provide any or all of the requested information may result delay or cancellation of services.

I certify that I have read and agree with Six Kind's Privacy Policy.

Company

Phone:
1-877-813-0803
Email:
info@sixkind.com

Social Media

Address

218 N. Lee Street, Ste. 314 Alexandria, VA 22314
Phone:
1-877-813-0 803
Email:
info@sixkind.com