Brij Appointment Intake Form

    MNsure is Minnesota's health insurance marketplace where individuals and families can shop, compare and choose health insurance coverage that meets their needs. MNsure is the only place you can apply for financial help to lower the cost of your monthly insurance premium and out-of-pocket costs. Most Minnesotans who enroll through MNsure qualify for financial help. https://www.mnsure.org/new-customers/whatis-mnsure/index.jsp
  • Medication List

  • Example: Tylenol 325mg twice a day for back pain
    Medication (example: Tylenol)Dose (325mg)Frequency (twice a day)Reason (back pain) 
  • This field is for validation purposes and should be left unchanged.

This form is not to be used for solicitation or advertising purposes. The information you’ve provided will only be used by our staff to contact you and will never be released to third parties. For more details, please review our privacy policy. By submitting your information to Brij Health, you agree to our website’s Terms and Conditions. We ask you to review these Terms and Conditions prior to submitting your information.