Request Support

Agency Information

Staff Name

Site Name

Staff Email

Participant Information

Email(Required)

Enter staff email if no participant email available

Cell Phone(Required)

Enter 000-000-0000 if no cell number available

Landline

Required only if no cell number available

Name for Registration (Not required if File Number exists)

First Last

File Number (If applicable)

Reason for Contact

Registration for a New Account

Existing Account Troubleshooting

Other: will describe during appointment

Preferred Times and Dates for being contacted (Optional)

Please indicate the best time and day of the week to be contacted. Note that we will try our best to accommodate your preferences.

Consent(Required)

Agrees to being contacted by phone by the GetaKit team.

Registration for an account should take approximately 30 minutes. The Consent Forms for participating will be reviewed for you to decide if you want to continue with registration.

Troubleshooting for a participant with an existing account will take approximately 15 minutes.

Please email us if there are changes at [email protected] Note that Personal Health Information should not be shared via email, and should instead be shared during the telephone call.