Become a patient / Hacerse paciente
We’d love to learn a little about you before you join so we can guide you to the right next step.
Preferred language
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English
Spanish
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Dr. Andrews is currently accepting a limited number of new patients.
Please complete this intake questionnaire to get started. Once submitted, you’ll be prompted to schedule a complimentary Meet & Greet.
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
Please enter your full name.
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First Name
Last Name
Email
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example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you find out 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
Previous member of Direct Primary Care of West Michigan
Other
Do you currently have a primary care clinician?
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No
Yes, I want to change
Yes, keeping both/dual care
Are you familiar with the basic concept of Direct Primary Care?
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Yes
No
Unsure
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?
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How would you describe your current experience with healthcare? What works well, and what could be improved? (Optional)
What are your primary health concerns or goals right now?
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Submit
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Doy mi consentimiento para que Direct Primary Care of West Michigan se ponga en contacto conmigo para hablar sobre la membresía y entiendo que este formulario no es una visita clínica.
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Estoy de acuerdo
¿Cómo se enteró de Direct Primary Care of West Michigan?
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Redes Sociales
Boca a Boca/Recomendado por un amigo
Recomendado por otro proveedor médico
Paciente anterior del Dr. Amat
Other
¿Actualmente tiene un médico de atención primaria?
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No
Sí, quiero cambiar
Sí, mantener ambos/la atención dual
¿Está familiarizado con el concepto básico de atención primaria directa?
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No
Si
¿Está dispuesto/a a pagar una cuota de membresía mensual y cualquier tarifa de laboratorio/diagnóstico?
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Si
No
No estoy seguro
¿Hay algo que debamos saber? (opcional)
Por favor ingrese su nombre completo.
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Nombre de pila
Apellido
Edad
Número de teléfono
Por favor, introduzca un número de teléfono válido.
Format: (000) 000-0000.
Correo electrónico
*
example@example.com
Submit
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