Membership Form — Concierge Integrative Pediatrics

1) Parent/Guardian Information

Full name*

Relationship to patient*

Mobile phone*

Email*

Address

2) Patient(s) Information

Child's name*

Date of birth*

Sex

3) Concierge Membership

Select the options that apply according to the number of enrolled children.

First child — $3,000/year Second child — $2,500/year Each additional — $2,000/year

Benefits include: direct contact 8:00 a.m.–10:00 p.m., same‑day appointments, expedited prescriptions, specialist referrals, dedicated support team, home visits (travel fee depends on address), and 1 complimentary holistic evaluation. You may still use your insurance for physicals and sick visits (coverage dependent).

4) Services of Interest

Same‑day appointments Expedited prescriptions Specialist referrals Medical home visits Holistic evaluation

Address for home visit

5) Insurance & Contact Preference

Insurance provider

Policy number

Preferred contact window

Preferred method

6) Acknowledgments

I understand direct pediatrician contact is available 8:00 a.m.–10:00 p.m., and outside these hours nursing staff will assist. I acknowledge the selected annual membership fees. I understand I may continue using my insurance for physicals and sick visits per coverage.

7) Signature

Printed name (signature)*

Date*

Draw your signature (finger on mobile or mouse on desktop)

Signature is optional. If you prefer, you can sign later.