G Tube Intake Form Facility Name: Facility Phone Number: Facility Email: Facility Address: Point of Contact Name: Number and specific type of tubes to be replaced: Number of patients: Condition of tubes Additional comment At Health Covers Online, we require a live consultation to ensure the treatments you select are tailored to your specific needs. We may contact you via phone, text, or email to schedule your consultation, as well as for appointment reminders, financial transactions, treatment-specific details, and marketing purposes. If you prefer, you can schedule your live consultation by calling us directly at (877) 811-4331. By submitting your information through the 'Book Appointment' page and clicking the SUBMIT button, you consent to receiving such communications, including recurring calls and texts, which may be sent using an automatic telephone dialing system or artificial/prerecorded voice technology. Consent is not required as a condition of purchase. Messages may be sent via SMS, MMS, or RCS technology. You can opt out at any time by texting STOP, or text HELP for assistance. Message frequency may vary, and standard message and data rates may apply. If you have any questions, please reach out—we’re here to help!