Thank you for your interest in GenHealth. Please complete the following information to set up your account.
  Required fields are noted with an asterisk (*)

 


       
Email (username):*      
   
       
First Name:* Middle Initial: Last Name:*  
 
       
Company:*      
     
Address 1:* Address 2:    
   
City:* State:* Zip:*  
 -  
       
Primary Phone:* Alt. Phone: Fax:  
(  )  - (  )  - (  )  -  



How did you hear about us?*  
How many appointments would you like to receive per week? (Minimum 2)*   
Cost of program: Starts @ $1410 for 30 appointments
(Prices vary by region)		 View plan details
Choose a state to receive appointments in.*  
Please enter your desired counties, towns, cities and/or zip codes:*
 
Please state your daily availability:*
Example for Time: 9-12am or All Day


Which electronic calendar system do you use?
Do you receive e-mails on a handheld device (mobile phone, Blackberry, Treo, etc.) that you check regularly?
Are you currently purchasing appointments or leads?
Which carriers are well known in your area?
 



Cardholder's name and address must match the billing address of the credit card.
   
Name on Card:*
Address:*
City:*
State:*
Zip:*  -
   
Credit Card Type:*
Credit Card Number:*  
Security Code:*
Expiration Date:* Month   Year


Please view and print the Service Agreement below for your records.

Please note:

Your account will be automatically renewed upon receiving the last appointment of your subscription.  At that time your credit card will be charged for the amount of a new subscription of appointments from your current program.  Should you cancel your subscription at any time before receiving your final appointment is scheduled, your credit card will not be charged for renewal. 

View Service Agreement