Join Us

Use this secure form to ENROLL WITH ANY HEALTHCARE PROFESSIONAL on the Signature Primary Care and Wellness team.  If you encounter any problems or prefer to enroll by phone, please call 614-710-0075.

Once you submit this enrollment form, we will contact you within a business day to confirm your membership, get to know your specific needs and schedule your first visit!

For Signature Primary Care memberships: Filling out this form does not guarantee membership or constitute establishing a physician-patient relationship.  We do not deny membership based on medical conditions, insurance status, age, race or any other personal factors.  Our patient panel is limited however and we will confirm our ability to properly care for your needs based on our clinicians' scope of practice and our panel capacity. We look forward to serving you!

For Signature Wellness Services (Counseling, Coaching, Yoga Classes, or Wellness Treatments): Thank you for enrolling.  We will contact you within a business day to confirm your specific needs and schedule your first visit!

Are you enrolling with Dr. Paige Gutheil?
Are you enrolling in Signature Wellness Behavioral Health services (counseling and coaching with Kevin)?
Are you enrolling in Signature Yoga?
Are you enrolling in a Signature Wellness service not mentioned above?
Are you a TRAIN Fitness House Member (

Basic Contact Information

Home Address

Contact Information

Emergency Contact

Health History

Please list significant current and past medical diagnoses:

Please list past surgeries:

Please list all current medications, vitamins, supplements:

Set Username and Password for Patient Portal

To gain online access to your medical records and secure communications, please create a username and password that you will use to log into the patient portal in the future.

  • Your username must be at least 4 characters long.
  • Each participating member on your account must have a unique username and password.

Your password must be at least 8 characters long and include at least one number or special character.


You are required to have a credit/debit card on file as a payment source for services and fees.  FOR SIGNATURE PRIMARY CARE MEMBERSHIPS, this will be used to automatically draft your monthly membership fee, however no charges will be made before your membership is accepted and specific fees are reviewed with you. FOR SIGNATURE WELLNESS SERVICES, this will be used to pay for services received at the time of service.

Card Details


Card Billing Address

Note: Signature Primary Care and Wellness does not bill insurance for its services with only the rare exception listed at Our clinicians are considered out of network providers with most insurances. Medicare beneficiaries are not permitted to seek reimbursement for SPC services from Medicare. We are happy to work with your insurance to process referrals, prescriptions, prior authorizations, etc.


On behalf of all of the members on this account, I understand and agree to the following (read and check all items indicating your acceptance):

For Signature Primary Care Memberships:

I will be charged a recurring fee per member for primary care services as described at and in the membership agreement below.

For Signature Wellness Services (Counseling, Coaching, or Yoga):

Service Primary Care members Non-members
Counseling with Kevin $50 $95
Yoga $10/session $15/session
$85/10-session package $120/10-session package

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