LOA Enrollment Portal
Use this form to enroll new patients or businesses. Your associated agent will earn commissions on all enrollments.
@if($agent)
Associated Agent: {{ $agent->user->name }} ({{ $agent->referral_code }})
@endif
Patient Information
Address Information
Plan Selection
@foreach($subscriptionPlans as $plan)
@endforeach
Note: The patient will receive an email with payment instructions to activate their subscription.
Enroll Patient
Business Information
Business Address
Contact Information
Billing Contact
HR Contact (Optional)
Plan Selection
Business plans are $20 per employee.
Minimum 1 employee required
Total Price: $@{{ (form.employee_count * 20).toFixed(2) }}
Note: The business administrator will receive an email with payment instructions to activate their subscription.
Enroll Business