FREE CONSULTATION
A Medberry admin will contact you, please complete and submit the health form.
Full Name
*
First Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
E-mail
*
example@example.com
When is a good time to call you?
*
Morning (9am-11am)
Afternoon (12pm-4pm)
Evening (5pm-9pm)
1. What are your main frustrations with your current healthcare provider?
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Long wait times
High costs or unexpected bills
Lack of personalized care
Difficulty scheduling appointments
Other
2. How often do you visit your primary care provider each year?
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1-2 times
3-5 times
More than 5 times
Rarely or never
3. What is most important to you in a healthcare provider?
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Affordable pricing
Easy and quick access to appointments
Personalized care and attention
Mental health or weight loss support
Transparency—no hidden fees or surprise bills
4. What are your top health goals?
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Managing weight
Improving overall physical health
Preventive care (e.g., annual checkups, screenings)
Mental health support (e.g., managing stress, anxiety)
Building a long-term relationship with my healthcare provider
Other
5. What concerns you most about your current healthcare experience?
*
I don’t have enough time to discuss all my concerns with my doctor
Healthcare is too expensive
My provider doesn’t understand my unique needs
It’s difficult to get an appointment when I need one
Other
Submit
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