Direct Primary Care (DPC) Membership Request Form

Join the interest list for Jan 1, 2026 enrollment. We’ll follow up to confirm pricing and availability.

Please note we may only check this a few times per day. Call the office for immediate assistance: 727-446-1097

First Name *

Last Name *

Phone *

Email *

Are you an Established Patient (seen in the last 3 years?) *

Yes

Location Preference (Clearwater - M/Tu/Th/F or Palm Harbor - Mon/Thurs)

Membership Plan Preferred *

Age Range *

10-20 years old

21-40 years old

41-60 years old

61+ years old

Anything we should know?

I'm inquiring for a company or group (DPC for employees)

By checking this box, I consent to receive transactional messages related to my account, orders, or services I have requested. These messages may include appointment reminders, order confirmations, and account notifications among others. Message frequency may vary. Message & Data rates may apply.Reply HELP for help or STOP to opt-out.

By checking this box, I consent to receive marketing and promotional messages, including special offers, discounts, new product updates among others. Message frequency may vary. Message & Data rates may apply. Reply HELP for help or STOP to opt-out.

HIPAA Notice: Please do not submit sensitive Protected Health Information (PHI) on this form. Use the CFMA Patient Portal for medical questions or to share clinical information. This form is for membership inquiries only and is not monitored 24/7. If you are experiencing a medical emergency, call 911.

Submitting does not enroll you; our team will follow up to confirm availability and pricing.