Please provide us with your insurance details so we can start working on your order
Email address
example@example.com
Gender
Female
Male
Date of birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
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12
13
14
15
16
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19
20
21
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25
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28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
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1971
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Primary Insurance Plan Name
*
Primary Insurance ID
*
Upload insurance card front (please confirm in preview that details are legible)
Upload insurance card back
What incontinence products are you using now?
Diaper / pad
External catheter
Other
Are you able to get out of bed independently?
Yes
No
Email
support@joinbetter.com
noemail@joinbetter.com
Submit
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