CCHP Hypertension Management Program

Please complete this form to sign-up for the program.

Once we receive your form, you will get your new blood pressure monitor (cuff) in the mail.
Your monthly bonus will be loaded to your Grocery Benefit Card upon checking your blood pressure twice a week.

"*" 指出所需的區域

名字*

字首名中名姓後綴

會員號碼*

出生日期 (月/日/年)*

電郵

Phone*

Sex at Birth*

Female

Male

Intersex

Decline to State

Would you like to use a different shipping address than the address we have on file?

Yes

Address*

Street Address Apt/Suite City State ZIP Code

Confirm*

是，讓我登記 CCHP 高血壓管理計劃

Phone

This field is for validation purposes and should be left unchanged.