Direct Primary Care - Individual

Holistic, Direct Primary Care

Please fill out the following form to secure your space in our practice.

Priority enrollment is for existing patients and begins October 1 and ends December 1, 2025. On December 1, enrollment will open to new patients.

Are you an existing patient?

If you are an existing patient AND you have OHP, you don't need to fill anything out. Please go get some Frite and Scoop and enjoy your day.

Yes (please just fill out name and date of birth)

No (please fill everything out)

Do you have OHP?

Yes (there is no cost to you for your care with us)

No (monthly subscription applies)

Legal Name

First Name

Last Name

Preferred Name

First Name

Last Name

Pronouns

Date of Birth

YYYY

only used for your care, unless you want to be on the mailing list, then check below.

Phone Number

(###)

###

####

Mailing Address

P.O. Boxes are fine :)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

May we have your consent to request and review your previous records?

By selecting "yes" below you are providing your consent for us to request pertinent medical records on your behalf to review and prepare to meet you. This helps us optimize the care we provide and give you a personal, effective experience. We will only request records for items which pertain to or affect the care we provide for you. Hooray! This is the last question for now. You may now go enjoy some Frite and Scoop!

Yes, I give consent for you to request pertinent health records from my previous provider

No, I do not give my consent to request previous records.

Not applicable. There are no previous records to obtain

Direct Primary Care - Individual

Holistic, Direct Primary Care

Astoria Birth Center & Family Medicine