Complete Healthcare of Oklahoma Registration

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Email Address

Your gender *

Male

Female

DOB (mm/dd/yyyy): *

Plan Information

Select Type of Plan: *

Primary Care Plan ($68/month)

Primary Care + Orthopedic ($99/month)

Primary Care + Urgent Care ($99/month)

Primary Care + Urgent Care + Orthopedic ($135/month)

Additional Services: *

Spouse or Additional Adult Family Member(+$68/month)

Child Primary Care (+$15/month per child)

None

Name of person who referred you to Complete Healthcare of Oklahoma. Refer a friend and you can earn $50.

Spouse Information

Only complete this section for your spouse, if your spouse will be participating in the CHO healthcare plan.

First Name of Spouse

Last Name of Spouse

Gender

Male

Female

DOB (mm/dd/yyyy):

Child Information

Only complete this section for your child or children if you desire them to be included for pediatric services

First Name of Child #1

Last Name of Child #1

Gender

Male

Female

DOB (mm/dd/yyyy):

First Name of Child #2

Last Name of Child #2

Gender

Male

Female

DOB (mm/dd/yyyy):

First Name of Child #3

Last Name of Child #3

Gender

Male

Female

DOB (mm/dd/yyyy):

Credit Card Information: Your credit card will be charged at the first of each month to continue your membership. Direct deposit from a checking or savings account can also be used as payment.

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

CID# *

Agree to Monthly Consultation Membership Agreement *

Yes

Your Credit Card will not be charged at this time. After submitting the form, a representative will call you to complete the registration process and verify payment.