Seth Premier Medical - Membership Request

Schedule your consultation with Seth Premier Medical.

At Seth Premier Medical, our membership-based model allows us to provide highly personalized care with fewer patients per physician. By eliminating the complexities of insurance, we focus entirely on your health through a simple annual membership.

Personal Information
What is your name?*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Email Address*
address@domain.com
Phone Number*
We'll use this to confirm your appointment.

Membership Details
Current Primary Care Physician (if applicable)
Why are you interested in joining Seth Premier Medical?*

Coordination of careConvenienceStronger relationship with physicianDiagnostic testingManagement of chronic conditionsPrevention and optimization
Please tell us about any other reasons for your interest in Seth Premier Medical.

Additional Information
Do you have medical insurance?

YesNo
How did you hear about our practice?*

Google / Search EngineFriend or familySocial mediaReferral by another doctor
Best Marketing Agency*

Macbach Healthcare Solutions

Confirmation
After you submit this form, our patient care coordinators will contact you during the current or next business day. Please indicate below if you consent to be contacted.
I consent to receiving communications regarding my appointment and understand that my information will be used in accordance with the practice's privacy policy.*

YesNo
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