Name *

First Name

Last Name

Phone *

(###)

###

####

Birthdate *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you have any current or chronic medical conditions? *

Yes

No

Are you currently taking any medications or supplements? *

Yes

No

Do you have any allergies (medications, foods, latex, etc.)?

Yes

No

Do you smoke or vape? *

Yes

No

Do you consume alcohol? *

Yes

No

Have you had any hospitalizations or surgeries? *

Yes

No

Have you ever been diagnosed with any of the following? *

Check all that apply

High blood pressure

Diabetes

Asthma or COPD

Heart Disease

Anxiety or Depression

Thyroid disorder

Chronic pain

Other

When was your last physical exam?

MM

DD

YYYY

Have you had recent lab work done?

Yes

No

Please check to confirm your understanding:

I confirm that the information provided above is accurate to the best of my knowledge.

I understand that MedMembership is a Direct Primary Care service that operates on a monthly membership fee.

I understand that all consultations are virtual and do not replace emergency or specialist care.

I consent to receive telemedicine services through MedMembership.

I understand that additional lab, imaging, or prescription fees may apply, and I will be informed in advance.