Thank you for your interest in KonnectMD.

Complete the information below and select your preferred appointment time. We will contact you to answer your questions and assist you with enrollment.

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Full Name *

Phone Number *

Email Address

Preferred Language *

• English
• Español

Who are you interested in enrolling? *

• Just Me
• My Family
• My Small Business
• I'm not sure yet

Approximately how many people need coverage? *

• 1
• 2-3
• 4-7
• More than 7

Full are the

What are you Most Interested in? *

• 24/7 Virtual Doctor Visits
• Prescriptions
• Mental Health
• Dental Savings
• Vision Savings
• Lab Discounts
• Imaging (MRI, CT, X-Ray)
• Healthcare for my Family
• Employee Benefits
• Affordable Healthcare Options
• Medical Debt Eraser
• Travel Protection
• I'm not sure—please explain my options.

(Check all that apply.)

Do you currently reside in the United States? *

• Yes
• No

Do you have one of the following? *

• Social Security Number (SSN)
• ITIN
• Neither

How would you prefer to meet? *

• Telephone
• Zoom
• In Person (where available)

Preferred Day (Sunday-Thursday) *

Preferred Time *

• Morning
• Afternoon
• Evening

What questions do you have before your appointment?

How did you hear about us? *

• Facebook
• Instagram
• TikTok
• YouTube
• WhatsApp
• Friend or Family
• Church
• Business
• Other

(Check all that apply.)

CONSENT *

• I authorize KonnectMD / LIG Healthcare Solutions to contact me regarding my request for healthcare membership information.
• I understand this request does not obligate me to purchase any membership.

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