New Client Form - PUHFhealth

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- Step 1 of 5

We're so glad you're hear! Answer a few questions to start your health journey today.

Name *

First

Last

Email *

Confirm Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

I have read and agree to the Terms of Service, Privacy Policy & Notice of Privacy Practice .

As a health care provider, PÜHF takes your privacy seriously. We won't share your information without your consent.

Agreement to Terms *

Yes, I agree

Already have an account?

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We help people sustainably lose weight and reverse thier type 2 diabetes. Tell us a little about yourself so we can create your personalized care plan.

Gender *

Sex at Birth

Birth Date *

Height *

Numbers

Weight *

Have you been diagnosed with diabetes? *

Are you sure?

People with type 1 diabetes don't make any insulin or very little. People with type 2 diabetes either don't make enough insulin, thier cells don't respond to insulin or both.

Do any of these situations apply to you? This helps us make sure that we can provide the right care for you. • I am currently on dialysis. • I use a pump or patch to administer my insulin. • I am currently pregnant. • I don't have access to a smartphone to engage in Virta's virtual care. • It is difficult for me to communicate about my medical care in English or Spanish. • I live outside the U.S. *

No, none of these apply to me.
Yes, one or more of these apply to me.

Sorry, we cannot provide care for you at this time.

We are committed to your safety and given you selected that one or more of these situations applies to you, we cannot monitor your health and progress in an outpatient setting.

• I am currently on dialysis.

• I use a pump or patch to administer my insulin.

• I am currently pregnant.

• I don't have access to a smartphone to engage in Virta's virtual care.

• It is difficult for me to communicate about my medical care in English.

• I live outside the U.S.

How will you be accessing PUHF care? *

I'll pay out of pocket
I'm covered, My employer, health plan or provider has told me that I'm covered for PUHF
I'm a US Verteran

The cost of PUHF is $299 per month

*There is a one-time $250 initiation fee paid up front.

If covered by an employer please select from the dropdown

Who is your Insurance Provider?

Please enter you Social Security Number (without the dashes)

Why are we asking this?

This information is only used to verify your health coverage through the

Veterans Health Administration

. Please note: To enroll in PUHF, you will need a referral from your VA primary care provider.

Let's get you set up

Create your account to unlock your next steps.

Mobile Phone Number *

Password *

Password

Confirm Password

How did you hear about us? *

about • I

We appreciate your interest!

A member of our onboarding team will be in touch shortly to coordinate a consultation and guide you through the next steps.