Become a Direct Primary Care Member

Become a Direct Primary Care Member

We're excited to welcome you! Please complete the form below to begin your Direct Primary Care membership. Once submitted, we'll review your information, activate your membership, and reach out to you for scheduling your first appointment.
Which membership are you enrolling in?
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
How did you hear about us?

Other
Insurance (Optional)

Although we don't bill insurance, having your insurance information can be helpful for coordinating care.
Insurance Company
Member ID
Current Health Snapshot
Current Medications (please list all)
Allergies (please include medication, food, and environmental)
Medical conditions you're currently being treated for
Current concerns or health goals
Policies
Please review the following:
Signature
Should be Empty:

Insurance (Optional)