New Customers
Check your eligibility to receive discreet, monthly deliveries of incontinence and other medical supplies direct to your door through your eligible Medicaid or other insurance plan.
Complete the form below and we will call you (within 1-2 business days) for a personal, and confidential, consultation about what’s covered by your insurance plan and what products are best for your needs.
New Customer Information
 
*Patient Name
 
*Patient''s Date of Birth
*Phone Number
*Email Address
 
*Address
*City
*State
*Zip Code
 
*Primary Contact Information (Who should we contact?)
 
*Primary Contact’s Name
 
*Primary Contact’s Phone Number
*Primary Contact’s Email Address
*Relation:
 
*How did you hear about us?
 
*Insurance Type (check all that apply)

 
*Supplies you would like more information about (check all that apply)

 
*By clicking the Submit Form button, I consent to receive autodialed and/or artificial/prerecorded voice marketing calls and/or texts from ActivStyle on the phone number provided above. I understand that I will receive these calls or texts even if I am on a federal or state do not call registry. I understand that my consent is not a condition of any purchase.