Requesting Additional Information

You recently signed up for our pre-launch waitlist! We'd like to get to know you better so we can personalize our services for you.
If you could please provide the information below, we'd really appreciate it!

It'll only take you a minute or two at the most.

Text

Your Contact Details - please correct as needed

First Name *

Last Name *

Phone

Email

General Information (fields with * are required)

What age range do you fall into? *

Under 18

18-24

25-34

35-44

45-54

55-64

65 or Above

Prefer not to say

Please select one option

Your Gender *

Male

Female

Prefer not to say

Please select your gender

Healthcare Options (fields with * are required)

Choose the option that best describes you *

I have health insurance with a low deductible

I have health insurance with a high deductible

I'm currently uninsured

I'm covered by Medicare

I'm covered by Medicaid

Direct primary care or concierge medicine

Prefer not to say

Please select one option

How do you typically get medical care for minor illnesses? *

Primary care doctor

Urgent care/walk-in clinic

Hospital emergency room

Telehealth/Telemedicine service

I usually wait until I feel better

Please select one or more

Which of these statements best describes your situation? *

I live in an area with plenty of healthcare options

I have limited healthcare options nearby

I have to travel 30+ minutes to reach medical care

I have difficulty accessing care due to my work schedule

I move frequently (college student, gig worker, digital nomad)

Please select one option

Are you primarily interested in ChatRx for *

Myself

My entire family

Children and/or parents

Someone else

Please select one or more

For which conditions would you use ChatRx? *

Respiratory infections (cold, flu, bronchitis)

Ear/eye infections

Sore throat/strep

Digestive issues

Sinus infections

Skin conditions (rashes, infections)

Urinary tract infections

Please select one or more

How did you hear about ChatRx? *

Healthcare provider

Search engine

Social media

Friend or family

News article

Online advertisement

Please select one or more

Which devices would you use to access ChatRx?

Smartphone

Tablet

Desktop computer

Laptop computer

Please select one or more

How would you like to receive updates? *

Email (updates only)

Email (updates & promotional offers)

Text message alerts

Social media updates

Postal mail

Please select one or more

Optional Information

The information below is optional but will help us customize your experience even more.

Education

High school

Some College, no degree

Bachelors degree

Masters, or higher

Prefer not to say

Please select one option

Income bracket

Up to $50,000

$50,000 to $99,9999

$100,000 to $149,999

$150,000 to $199,999

Over $200,000

Prefer not to say

Please select one option

Your Zip code

Please enter your primary zip code

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