Please fill in all fields with an * correctly, so that we may process your Patient Recommendation information quickly.
If you already have a Patient Recommendation on file that is current with us, you do not need to fill out this form.
Contact Us if you have any questions about that. (888) 99-Harborside (1-888-994-2726)

Member/General Information
Contact Email*:
First Name *:
Last Name *:
Gender:	Male Female
Date of Birth*:	Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000
Would you like to receive communications from HHC about specials, promotions, newsletters, action alerts, and more?
	Yes No
Harborside Health Center (HHC) has my permission to place calls to me at the number I provide in this Patient Verification Form, with information about HHC products or services in which I may be interested. I understand that as a result of giving this permission, I may be contacted by someone calling on behalf of HHC (even if my telephone number is listed on the federal "do not call" registry).
	Yes No
Military Veteran?:	Yes No
How did you find us?* (must choose one)
	Print Advertisement? SF Weekly SF Guardian Metro East Bay Express Bohemian	Internet Advertisement? Google Ad Facebook CANORML.org Yelp Weedmaps	. Harborside Health Center E-Newsletter Search Engine - Specify Google Yahoo MSN Bing Other Event - Specify Referred by: Other - Specify
Patient/Doctor Information
Doctor/Clinic Name *:
Doctor/Clinic Area Code *:
Doctor/Clinic Phone *:	Please format the # correctly, or you could get an error and not be able to continue.
Doctor/Clinic Web site:
Patient ID *:
Patient Recommendation: (attach file, JPG/GIF/BMP/PNG/PDF only) NOTE: All images must be readable and in focus to be accepted. We recommend using a scanner rather than a camera phone. Files can not be larger than 2 MB in size. If you can not provide now, it will be required upon first delivery. If your doctor does not have 24-hr phone or web site patient verification, we recommend attaching your recommendation here.
Recommendation Expiration Date *:	Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 2010 2011 2012 2013 2014
Patient/Recommendation ZIP code*:	(For verification purposes, the ZIP code on file with your doctor/clinic for your recommendation)
FOR NEW MEMBERS: Download this New Patient Agreement Form and have it signed and ready upon your first order.
Image Validation* (Input text from image, required to continue)	Can't read it?
	Input above Image Validation text here