Form
Pre-Enrollment Questionnaire for Dr. Matthew Hilton
Thank you for answering the questions below. 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 Momentum Medicine contacting me about membership and understand this form is not a clinical visit
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I Agree
Are you..
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Interested in transferring primary care to Dr. Matthew Hilton
Interested in a Non-Member appointment
How did you hear about Momentum Medicine?
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Social Media
Word of Mouth/Referral by a friend
Referral by another medical provider
Previous patient of Matthew Hilton, DO
Other
Do you currently have a primary care physician?
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No
Yes, wanting to change
Other
What are your primary health concerns or goals right now?
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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 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 else we should know? (Optional)
Name
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Prefix
First Name
Last Name
Suffix
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
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example@example.com
Submit
Should be Empty: