Whole Family Medicine Waiting List
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.) *
Your answer
List any important health concerns that you have for you and your family. Take as much space as you need. *
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.) *
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.) *
While you are on the waiting list, would you like to receive our newsletter?
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