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
What brought you here?
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Long-term primary care
Acute issue / urgent
Specialty second opinion
Only labs/letters
Do you currently have a primary care clinician?
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No
Yes, want to change
Yes, keeping both/dual care
Do you have chronic conditions requiring frequent specialist care?
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No
Yes — insulin pumps/IV meds/transplants, etc.
Yes - chronic disease (diabetes, HTN, CKD stage 1–3, etc)
Other
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
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 or need sliding scale
Anything we should know? (optional)
Please enter your full name.
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First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
Date
Phone Number
Please enter a valid phone number.
Email
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example@example.com
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