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 *

Phone number *

Email address *

How did you hear about Whole Family Medicine? *

How many people would you like to enroll as members? List adults and children separately. (Family rates are available.) *

List any important health concerns that you have for you and your family. Take as much space as you need. *

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.) *

Yes

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

While you are on the waiting list, would you like to receive our newsletter?

Yes

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