Name Sign Up/New Patient Verification Form Pre-registration requests are usually processed within 24hrs. Some doctor's offices can take up to one week to verify recommendations letters. Please use this form if you are requesting delivery or if you are planning a visit in the next few days. We will contact you and let you know as soon as your pre-registration is complete. Please make sure to bring your ID and recommendation upon your first visit, or have it ready for your first delivery. Contact Email * First Name * Last Name * Gender * Male Female Date Of Birth * Military Veteran Yes No To order for delivery, please enter your address: Street Address * City * ZIP * Phone Number * Permission * Yes No Mr Nice Guy's has my permission to place calls to me at the number I provide in this Patient Verification Form, with information about Mr Nice Guy's products or services in which I may be interested. I understand that as a result of giving this permission, I may be contacted by someone calling on behalf of Mr Nice Guy. Specials Yes No Would you like to receive communications from Mr Nice Guy's about specials, promotions, newsletters, action alerts, and more? Doctor / Clinic Information Doctor/Clinic Name *: * Phone Verification Website: Patient ID *: Recommendation Expiration Date *: * Patient/Recommendation ZIP code *: (For verification purposes, the ZIP code on file with your doctor/clinic for your recommendation) Please make sure to also bring your Doctor's recommendation and ID with you to your first visit.