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Whole Family Medicine Waiting List
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Before completing this form, it is important that you review the sections on membership and FAQs on our website (
wholefamilymed.com
).
Your name
*
Your answer
Phone number
*
Your answer
Email address
*
Your answer
How did you hear about Whole Family Medicine?
*
Your answer
How many people would you like to enroll as members? List adults and children separately. (Family rates are available.)
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Your answer
List any important health concerns that you have for you and your family. Take as much space as you need.
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Your answer
Are you aware that WFM membership requires an initial assessment fee, monthly membership payments, and a one-year commitment? (Currently $200/month for an individual; family pricing available. See website for details.)
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Yes
No
Are you aware that WFM is not a substitute for insurance and that we will bill your insurance for covered services and collect any co-pays required by your plan? (See website FAQ.)
*
Yes
No
While you are on the waiting list, would you like to receive our newsletter?
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