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New Patient & Consultation Interest Form
Start your journey with Direct Primary Care of West Michigan. Please follow the steps below to help us best understand your needs. After you complete this form you will be redirected to schedule a free Meet & Greet.
Full Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Preferred method of communication
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Text
Email
Phone
Are you familiar with the basic concept of Direct Primary Care?
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Yes
No
Somewhat
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What brings you in today? (Select all that apply)
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Primary Care Membership — For ongoing primary care, direct access to your doctor, and comprehensive preventive and acute care.
Metabolic Health Consultation — For insulin resistance, PCOS/PMOS, weight resistance, inflammation, prediabetes, cholesterol concerns, and metabolic health.
Hormone Health Consultation — For perimenopause, menopause, cycle concerns, fatigue, libido, hormone symptoms, and hormone optimization.
Gut Health Consultation — For bloating, digestive symptoms, gut concerns, food sensitivities, microbiome concerns, and chronic digestive issues.
I'm not sure — please help me determine the best fit — Many patients overlap between programs. Select this and we'll help guide you.
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Do you currently have a primary care clinician?
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Yes
No
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Are you willing/able to pay a monthly membership fee and any lab/diagnostic fees if applicable?
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Yes
No
I have questions about this
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What are your primary health concerns or goals right now?
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What led you to consider direct primary care instead of traditional insurance-based primary care practice? (OPTIONAL)
OPTIONAL
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How would you describe your current experience with healthcare? What works well, and what could be improved? (OPTIONAL)
OPTIONAL
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Why are you interested in our practice specifically? (OPTIONAL)
OPTIONAL
How do you prefer communicating with your doctor for non-urgent matters?
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Text/SMS
Patient portal message
Email
Phone call
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How did you hear about Direct Primary Care of West Michigan?
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Please Select
Google search
Social media
Friend or family referral
Current patient referral
Local event
Physician referral
Other
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Anything else we should know? (OPTIONAL)
OPTIONAL
Anything else we should know? (OPTIONAL)
OPTIONAL
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I consent to Direct Primary Care of West Michigan contacting me about membership and understand this form is not a clinical visit.
*
I consent
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