First Name *

Last Name *

Email *

Phone *

Date of Birth *

Do you currently have a primary care provider? *

Yes

If yes, why are you switching or supplementing? *

What is the primary medical reason you're seeking Direct Primary Care? *

Preventive care

Chronic illness management

Acute/urgent needs

Wellness support

Weight loss

Women's Health

Other

(Please select all that apply.)

Do you currently have health insurance? *

Yes

If yes, who is your current health insurance provider? *

Is your insurance provider an HMO? *

Yes

Are you seeking pain/opiod medication management? *

Yes

Are you currently using or have a history of using controlled substances (e.g., opioids, benzodiazepines)? *

Yes

If yes, please list: *

Are you aware that Direct Primary Care is a membership-based model that typically does not bill insurance? *

Yes, I am aware that this is a subscription model and that my health insurance will not be billed for my visits.

No, I was not aware that I am unable to use my existing insurance for coverage.

How did you hear about us? *

Doctor Referral
Friend/Family
Google Ad
Social Media
Web Search
Other
No elements found. Consider changing the search query.
List is empty.

Please share who referred you, so we can be sure to thank them: *

Anything else you'd like us to know?

Please do not share any personal or sensitive information including medical issues, medications, etc.

By checking this box, I consent to receive transactional and promotional messages messages related to my account, services I have requested, special offers, among others. Message frequency may vary. Message & Data rates may apply. You may opt out at any time by replying STOP.