Direct Primary Care Intake
Provide your details and preferences to get started with our wellness program.
First Name
*
First Name
Last Name
Last Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Call
Text
State of Residence
*
Please Select
Texas
Colorado
Florida
Iowa
Vermont
Virginia
Washington
Connecticut
How did you hear about us?
*
Please Select
Google Search
Instagram
Referral
Other
What are you looking for in a DPC membership? (Select all that apply)
*
A consistent provider who knows me
Preventive and wellness-focused care
Management of stable chronic conditions
Medication management and refills
Telehealth convenience
Insurance-free transparent pricing
Whole-body integrative approach
Do you currently have insurance?
*
Yes
No
Yes but prefer cash-pay
Do you understand that DPC does not include hormone therapy, GLP-1 programs, peptide therapy, controlled substances, or emergency care?
*
Yes, I understand
I have questions about this
Is there anything about your health history or goals we should know before reaching out?
Enrollment is by provider approval only. Completing this form does not guarantee membership.
Submit
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