0001779388-24-000001.txt : 20240626 0001779388-24-000001.hdr.sgml : 20240626 20240626144403 ACCESSION NUMBER: 0001779388-24-000001 CONFORMED SUBMISSION TYPE: D PUBLIC DOCUMENT COUNT: 1 ITEM INFORMATION: 06b FILED AS OF DATE: 20240626 DATE AS OF CHANGE: 20240626 EFFECTIVENESS DATE: 20240626 FILER: COMPANY DATA: COMPANY CONFORMED NAME: Form Health, Inc. CENTRAL INDEX KEY: 0001779388 ORGANIZATION NAME: IRS NUMBER: 834453240 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 FILING VALUES: FORM TYPE: D SEC ACT: 1933 Act SEC FILE NUMBER: 021-516986 FILM NUMBER: 241073054 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 1 primary_doc.xml X0708 D LIVE 0001779388 Form Health, Inc. 109 State Street 5th Floor Boston MA MASSACHUSETTS 02109 6179013644 DELAWARE Occom Medical Weight Loss, Inc. Corporation true 2019 Evan Richardson c/o Form Health, Inc. 109 State Street, 5th Floor Boston MA MASSACHUSETTS 02109 Executive Officer Director Promoter Latif Peracha c/o Form Health, Inc. 109 State Street, 5th Floor Boston MA MASSACHUSETTS 02109 Director Other Technology Decline to Disclose 06b false 2024-06-12 false true false 0 38000000 32999982 5000018 Amounts include conversion of outstanding convertible securities. false 7 0 0 0 false Form Health, Inc. /s/ Evan Richardson Evan Richardson President 2024-06-26