Personal Information
- Full Legal Name: ________________
- Date of Birth: //___
- Social Security Number: --___
- Home Address: ________________
- Email Address: ________________
- Preferred Phone: ________________
- Emergency Contact: ________________
Medical History
- Primary Care Physician (Previous): ________________
- Preferred Pharmacy: ________________
- Current Medications: ________________
- Known Allergies: ________________
- Chronic Medical Conditions: ________________
Concierge Service Agreement
- Annual Membership Fee: $______
- Payment Method: □ Annual □ Semi-Annual □ Quarterly
- Services Included:
- 24/7 Direct Physician Access
- Same/Next Day Appointments
- Extended Visit Times
- Preventive Care Services
- Coordinated Specialist Care
Insurance Information
- Primary Insurance: ________________
- Policy Number: ________________
- Group Number: ________________
- Secondary Insurance (if applicable): ________________
Consent and Acknowledgment
- I understand that the concierge membership fee is not covered by insurance
- I acknowledge receipt of the practice's privacy policy
- I authorize release of medical information as needed for care coordination
Signature: ________________ Date: //___
Office Use Only
- Membership Start Date: //___
- Assigned Physician: ________________
- Account Number: ________________