Use this form to enroll new patients or businesses. You'll earn commissions on all enrollments.
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As an agent, you can only offer Premium Plans (IDs 7-11) to your clients.
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Patient Information
Address Information
Plan Selection
@foreach($subscriptionPlans as $plan)
@endforeach
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Note: Only Premium Plans (IDs 7-11) are available for agent enrollments.
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Enroll Patient
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Business plans are active until the end of the current month ({{ \Carbon\Carbon::now()->endOfMonth()->format('F j, Y') }}). The business will need to renew their plan for the next month.
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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) }}