Family Membership Form – Faith Family Medical

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- What is DPC?
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membership registration for family plan

Please fill out the form below to become a member of Faith Family Medical.

registration form

Membership Choice

The family membership includes 2 adults and 2 children. If you want to add additional children, please enter the number of additional children hereYour family membership includes 2 children. Additional children will add $20 per month per child to your membership

Monthly Total

$

Yearly Total

Would you like to pay monthly or yearly?MonthlyYearly

Adult #1

Member Information

Full Name *

Preferred Name

Sex *MaleFemale

Date of Birth *

Contact Information

Email Address *

Mobile Phone *Valid mobile phone required

Add another phone number?YesNo

Other Phone

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Adult #2

Member Information

Full Name *

Preferred Name

Sex *MaleFemale

Date of Birth *

Contact Information

Email Address #2 *

Mobile Phone *Valid mobile phone required

Add another phone number?YesNo

Other Phone

Is your address the same as Adult #1? *YesNo

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Child #1

Member Information

Full Name *

Preferred Name

Sex *MaleFemale

Date of Birth *

Contact Information

Is this patient's contact information the same as Adult #1 and Adult #2? *YesNo

Mobile PhoneValid mobile phone required

Add another phone number?YesNo

Other Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Child #2

Member Information

Full Name *

Preferred Name

Sex *MaleFemale

Date of Birth *

Contact Information

Is this patient's contact information the same as Adult #1 and Adult #2? *YesNo

Mobile PhoneValid mobile phone required

Add another phone number?YesNo

Other Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Additional Child

Member Information

Full Name

Preferred Name

SexMaleFemale

Date of Birth

Contact Information

Is this patient's contact information the same as Adult #1 and Adult #2?YesNo

Mobile PhoneValid mobile phone required

Add another phone number?YesNo

Other Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Communication Agreement *

On behalf of each patient in this membership:

I authorize Faith Family Medical Services, LLC to send email or text which may include unencrypted protected health information. Learn More

Patient Agreement *

On behalf of each patient in this membership:

I have read and agree to the patient agreement for Faith Family Medical Services, LLC. Faith Family Medical Membership Agreement

Total per month:

$

Total per year:

$

Credit / Debit Card *

6050 Airline Road, Suite 109

Arlington, TN 38002

(901) 867-3367

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About
Memberships
Functional Medicine
Aesthetics
Employers
Contact
Privacy Policy
Terms & Conditions