FLORIDA ADDRESS (same as driver's license) *
If your FL address does not match the address on your driver's license, please stop and speak with the KindHealth staff.
FL County * Miami-Dade Broward Alachua Baker Bay Bradford Brevard Calhoun Charlotte Citrus Clay Collier Columbia Desoto Dixie Duval Escambia Flagler Franklin Gadsden Gilchrist Glades Gulf Hamilton Hardee Hendry Hernando Highlands Hillsborough Holmes Indian River Jackson Jefferson Lafayette Lake Lee Leon Levy Liberty Madison Manatee Marion Martin Monroe Nassau Okaloosa Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Putnam Santa Rosa Sarasota Seminole St. Johns St. Lucie Sumter Suwannee Taylor Union Volusia Wakulla Walton Washington WEIGHT (lb) * Age * PREGNANT or PLANNING to be? * Are you currently breast feeding? * Was last cycle over 28 days ago? * Why was your cycle late? * Please explain * Florida Qualifying Conditions (check any that apply) Don't see your problem yet? Check here. None Alzheimer's Cerebral Palsy Degenerative Disc Disorder Fibromyalgia Herniated Disk Irritable Bowel Syndrome Lupus Lyme Disease Muscle Spasms Myasthenia Gravis Myositis Neuropathy Osteoarthritis Osteoporosis Peripheral Vascular Disease Polymyalgia Rheumatica Post-Polio Syndrome Psychiatric Conditions Reflex Sympathetic Dystrophy Rheumatoid Arthritis RLS (Restless Legs Syndrome) Scoliosis Seizures Sickle Cell Anemia Spasticity Spinal Stenosis Tourette's Ulcerative Colitis Have you used any other medical treatments?
What types of treatments have you taken for your medical condition in the past?