NEW PATIENT Family Membership – Faith Family Medical

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NEW PATIENT REGISTRATION FOR FAMILY MEMBERSHIPS

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

Please note, there will be a one-time $99 enrollment fee for each adult in the membership

registration form

Membership Choice

Would you like to pay monthly or yearly? *MonthlyYearly

Select *

Select *

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

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

Child #3

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

Child #4

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

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