HAWS Registration

Please fill out this form to complete your registration with the most cutting-edge health and wellness assessment available anywhere. We just need a few details and you'll have full access to HAWS. If you have any questions or need and help, please email HAWS support at info@healthandwellnessscore.com or call us at 678-807-8457 and we'd be glad to answer any questions.

Business/Practice Information

First Name:

Last Name:

Practice Name:

Office Address:

Office Address(2):

City:

State:    Zip:

Phone:

Email:

Website:

Best day and time to contact:

How did you hear about us:

Credit card information

This website employs highly secure 256-bit encryption for your safety. HAWS does not store any of your financial information on our servers.

Credit card number:

CVV:

Exp Date:

I understand a one time charge of $100 will be billed now, with a $40/month recurring payment billed every month until I give written/ email notification to stop.