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.
Welcome to Direct Primary Care of West Michigan / Bienvenido a Direct Primary Care of West Michigan
Full Name
*
First 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 method of communication
*
Text
Email
Phone
What brings you in today?
*
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.
Primary Care Membership — For ongoing primary care, direct access to your doctor, and comprehensive preventive and acute care.
I'm not sure — please help me determine the best fit — Many patients overlap between programs. Select this and we'll help guide you.
Do you currently have a primary care clinician?
*
Yes
No
Are you familiar with the basic concept of Direct Primary Care?
*
Yes
No
Somewhat
Are you willing/able to pay a monthly membership fee and any lab/diagnostic fees?
*
Yes
No
I have questions about this
What are your primary health concerns or goals right now?
*
If you are familiar with direct care, what led you to consider this instead of traditional insurance-based primary care?
*
How would you describe your current experience with healthcare? What works well, and what could be improved?
*
Why are you interested in our practice specifically?
*
How do you prefer communicating with your doctor for non-urgent matters?
*
Text/SMS
Patient portal message
Email
Phone call
How did you hear about Direct Primary Care of West Michigan?
*
Please Select
Google search
Social media
Friend or family referral
Current patient referral
Local event
Physician referral
Other
Anything else we should know?
I consent to Direct Primary Care of West Michigan contacting me about membership and understand this form is not a clinical visit.
*
I consent
Submit
Should be Empty: