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Employer DPC Interest Form
I consent to Direct Primary Care of West Michigan contacting me about membership and understand this form is not a clinical visit.
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I consent
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Business Name
*
Industry
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Name of the person completing this form
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First Name
Last Name
Your Role/Title
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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
Approximately how many employees do you have?
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Do you currently offer health insurance?
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Yes
No
Planning to
When is your next benefits renewal?
What are your biggest healthcare challenges? (Select all that apply.)
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Rising insurance costs
Difficulty getting appointments
Employee recruitment/retention
Employee health and wellness
High deductibles
Other
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How familiar are you with Direct Primary Care?
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New to it
Somewhat familiar
Very familiar
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
What would you like to learn more about?
Please Select
Membership pricing
Employer plans
Integrating DPC with insurance
Employee wellness
Not sure yet
OPTIONAL
Is there anything else you'd like us to know?
OPTIONAL
Submit
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