0001779388-23-000001.txt : 20230113 0001779388-23-000001.hdr.sgml : 20230113 20230113145140 ACCESSION NUMBER: 0001779388-23-000001 CONFORMED SUBMISSION TYPE: D/A PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b FILED AS OF DATE: 20230113 DATE AS OF CHANGE: 20230113 EFFECTIVENESS DATE: 20230113 FILER: COMPANY DATA: COMPANY CONFORMED NAME: Form Health, Inc. CENTRAL INDEX KEY: 0001779388 IRS NUMBER: 834453240 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: D/A SEC ACT: 1933 Act SEC FILE NUMBER: 021-397425 FILM NUMBER: 23528454 BUSINESS ADDRESS: STREET 1: 4 BRADFORD ROAD CITY: NEWTON STATE: MA ZIP: 02461 BUSINESS PHONE: 6179013644 MAIL ADDRESS: STREET 1: 4 BRADFORD ROAD CITY: NEWTON STATE: MA ZIP: 02461 FORMER COMPANY: FORMER CONFORMED NAME: Occom Medical Weight Loss, Inc. DATE OF NAME CHANGE: 20190607 D/A 1 primary_doc.xml X0708 D/A LIVE 0001779388 Form Health, Inc. 17 Lincoln Street #404 Boston MA MASSACHUSETTS 02111 6179013644 DELAWARE Occom Medical Weight Loss, Inc. Corporation true 2019 Evan Richardson c/o Form Health, Inc. 17 Lincoln Street #404 Boston MA MASSACHUSETTS 02111 Executive Officer Director Promoter Latif Peracha c/o Form Health, Inc. 17 Lincoln Street #404 Boston MA MASSACHUSETTS 02111 Director Other Technology Decline to Disclose 06b true 0001779388-22-000001 2021-04-13 true true false 0 23859597 22884578 975019 false 12 0 0 200000 true false Form Health, Inc. /s/ Evan Richardson Evan Richardson President 2023-01-13