CCPA REQUEST FORM

At Wellfit, we recognize that our relationship with you is based on integrity and trust, so we first need to verify your identity. Please complete this form so that we may begin that process. It is critical that all of your information is entered accurately to ensure optimal results.

If you have Power of Attorney, Legal Guardianship, or other adjudication of authority to act in this capacity for another person and are submitting a request on behalf of that person, please send a letter containing the request type(s) e.g. (Request to Know, Delete) together with a copy of your adjudication of authority to:

Compliance Department
Wellfit Technolgies, Inc
P.O. Box 140309
Irving, TX 75039

I am a(n)

Existing patient Not a patient

Type of Request - Choose One

First Name

Middle Name

Last Name

Suffix

Date of Birth(MM/DD/YYYY)

Country Code:

Mobile Number

Phone Number

Current Address

City

State

Zip

Previous Address Same as Current

Previous Address

Previous City

Previous State

Previous Zip

I certify under penalty of perjury that I am the individual named in this form, and the information provided herein is accurate and complete to the best of my knowledge.

Disclosure:

By submtitting this request, I consent to receive phone cakes from Wellfit, at the phone number above, including my wireless number if provided, for purposes of processing my CCPA request.

Platform

Company

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