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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
Additional Information (Optional)
Feel free to 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.
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