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 614-878-0600.

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: 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 in a Signature Primary Care monthly membership with a physician?
Are you enrolling in Signature Wellness Behavioral Health services (counseling and coaching)?
Are you enrolling in Signature Health Coaching?
Are you enrolling in Signature Yoga?

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.

Billing

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.

Card Details

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Card Billing Address


Note: Signature Primary Care and Wellness does not bill insurance for its services with only the rare exception listed at SignaturePrimaryCareandWellness.com. Our clinicians are considered out of network providers with most insurances and are unable to provide a superbill for the purposes of being reimbursed by insurance companies. 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.

Authorizations/Acknowledgements:

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 SignaturePrimaryCareandWellness.com and in the membership agreement below.

For Signature Wellness Services:

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