Membership Enrollment — The Country Doctor

Name

First Name

Last Name

Date of Birth

YYYY

Gender

For setting up patient portal (*note: you may enter "decline to answer" )

Membership Plan

Please Select One

Root Causes Plan (unlimited visits per month + membership benefits)

Docere Plan (up to 2 visits per month + membership benefits)

Vis Plan (one visit per month + membership benefits)

Wellness Basics Plan (Annual visit / Well Child visits + Membership Benefits) (individual)

Wellness Basics Plan (Annual Visit / Well Child visits + Membership Benefits) (family)

Additional Family Members (for family plans only)

Please add the following for additional family members: name, DOB, gender, email address

Membership Enrollment.