Pre-Enrollment Questionaire 🌱
We’d love to learn a little about you and what matters most to your health before you join. Your answers help us prepare for a smoother, more personalized experience.
I consent to Direct Primary Care of West Michigan contacting me about membership and understand this form is not a clinical visit.
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I agree
How did you hear about Direct Primary Care of West Michigan?
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Social Media
Word of Mouth/Referred by a friend
Referred by another medical provider
Previous patient of Dr. Andrews
Other
Do you currently have a primary care clinician?
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No
Yes, want to change
Yes, keeping both/dual care
What are your primary health concerns or goals right now?
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Are you familiar with the basic concept of direct primary care?
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No
Yes
If you are familiar with direct care, what led you to consider this instead of traditional insurance-based primary care? (Optional)
Why are you interested in our practice specifically? (Optional)
How would you describe your current experience with healthcare? What works well, and what could be improved? (Optional)
How do you prefer to receive care?
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Mostly virtual and messaging + occasional office visits
Mostly in-person office visits
Require same-day in-person care often
A mixture of all of the above
How do you prefer communicating with your doctor for non-urgent matters?
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Phone Calls
Text Messages
Emails
In Person
Are you willing/able to pay a monthly membership fee and any lab/diagnostic fees not covered by insurance?
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Yes
No
Not sure
Anything we should know? (optional)
Please enter your full name.
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First Name
Last Name
Date of Birth
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Month
 -
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
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example@example.com
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