Squire - Individual Sign-Ups

Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Language
Date of Birth

MonthDayYear
Age restrictions apply: Primary account holder must be 18-64 years old.

Payment / Billing Details

Plan Selection

Vitable Primary Care - Squire Membership

Get access to delightful virtual and in-home primary care along with mental health, free prescriptions, labs, annual wellness visits, and more. $0 copays and no deductibles to access primary care. Family members and dependents are covered for free. Your subscription will take up to Five Days to activate.

Free for the first Five Days then, $60.00 for each month

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Payment / Billing Details

Plan Selection*

Plan Selection