im365health.com - Become A Member

Welcome to IM365 Health

Thank you for your interest in IM365 Health. We believe exceptional healthcare begins with understanding you—not just your medical history, but your goals, priorities, and what matters most to you.

This brief questionnaire is an opportunity to share your expectations so we can personalize your experience from day one. The more thoughtfully you complete it, the better prepared our team will be to make your first conversation meaningful and productive.

⏱️ Takes 2–5 minutes: By completing this, you help us maximize the value of your concierge care and build a strong foundation for a long-term health partnership.

*There are no right or wrong answers—we simply encourage you to answer openly and honestly.

We look forward to getting to know you.

Full Name

First NameMiddle NameLast Name

Preferred Name (Optional)

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

1. What prompted you to begin looking for a new primary care physician?

2. What made you decide to inquire about IM365 Health today?

3. What are you hoping will be different about your healthcare experience?

4. What are your top health priorities over the next year?

5. Which statement best describes you?

6. What has been your biggest frustration with healthcare?

7. What does exceptional healthcare look like to you?

8. How important are the following?

Rows	Very Important	Important	Somewhat Important	Not Important
Longer appointments
Direct access to your care team
Preventive care
Coordination with specialists
Building a long-term relationship with your physician

9. How do you prefer to communicate with your healthcare team?

10. Is there anything you'd like your physician to know before meeting you?

Title

Gender

Age

Address

Address Line 1

Address Line 2

CityState / Province

Postal / Zip Code

Current Primary Care Physician

What are your reasons for wanting to transition your care to IM365 Health?*

Please select all that apply

Other reasons why you are interested in concierge medicine

Please tell us about any other reasons for your interest in IM365 Health (if applicable). Please do not include medical details.

How did you hear about us?

If Other, please share details in the Comments field

Comments

Please share additional information about how you heard about us. If someone referred you, please let us know their name.

Family members interested in joining IM365 Health?

Please provide the name, relationship, and age for each family member interested in joining (if applicable)

IM365 Health Prospective Member Questionnaire

Welcome to IM365 Health

About You