DPC One Sign Up

DPC One Sign Up
Thank you for your interest in becoming a member of DPC One, ViaroCare’s comprehensive Direct Primary Care plan. The information you provide in this form is collected securely and will be used to prepare your membership documents. Once your submission is received, a member of the ViaroCare Patient Care Team will reach out to guide you through the final steps of completing your agreement and activating your membership.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Include Fitness Center add-on?*

YesNo
Add Dependents?
Amount of dependents to add. Please leave blank for no dependents.
Name of Dependent 1*

First NameLast Name
DOB Dependent 1*

MonthDayYear
Date
Relationship of Dependent 1*
Fitness Center add-on Dependent 1*

YesNo
Name of Dependent 2*

First NameLast Name
DOB Dependent 2*

MonthDayYear
Date
Relationship of Dependent 2*
Fitness Center add-on Dependent 2*

YesNo
Name of Dependent 3*

First NameLast Name
DOB Dependent 3*

MonthDayYear
Date
Relationship of Dependent 3*
Fitness Center add-on Dependent 3*

YesNo
Name of Dependent 4*

First NameLast Name
DOB Dependent 4*

MonthDayYear
Date
Relationship of Dependent 4*
Fitness Center add-on Dependent 4*

YesNo
Name of Dependent 5*

First NameLast Name
DOB Dependent 5*

MonthDayYear
Date
Relationship of Dependent 5*
Fitness Center add-on Dependent 5*

YesNo
Name of Dependent 6*

First NameLast Name
DOB Dependent 6*

MonthDayYear
Date
Relationship of Dependent 6
Fitness Center add-on Dependent 6*

YesNo
Should be Empty: