Loudoun Holistic Concierge Medicine Membership Application Form

Please complete the form below to request an application for membership in the Loudoun Holistic Concierge Medicine Program for the 2019-2020 membership period. We will email you your 2019-2020 membership enrollment and registration documents once we receive your completed application.

LHHP Concierge Medicine Membership Application Form

New Member Application

If you are human, leave this field blank.

Primary Applicant First Name *

Primary Applicant Last Name *

Primary Phone Number (Best Phone Number to Call You) *

Alternate Phone Number (If available)

Email Address (Enter the email address to which we should send your membership application documents) *

Primary Applicant Mailing Address *

Primary Applicant Date of Birth *

Primary Applicant Membership Category Requested *

Wellness

Restoration

Elite Thrive

Vitality

Visit this link to view and download the Membership Information Packet with full details on Membership Categories and associated fees: https://loudounholistichealthpartners.com/wp-content/uploads/2017/08/lhhp-member-info-packet-8-04-2017.pdf

Is the primary applicant a current LHHP patient or a new LHHP patient? *

Current Patient

New Patient

Preferred Payment Schedule for Primary Applicant (Choose One Option) *

Monthly

Annual

Preferred Payment Payment Method *

Credit Card on File (3.5% Processing Fee Added)

New Credit Card (Call LHHP Office with Credit Card Info - 3.5% Processing Fee Added)

Bring a check to the office (annual payment option only - no fee)

ACH Withdrawal (No Fee)

Second Applicant Name (optional)

Second Applicant Date of Birth

Is the second applicant a current LHHP patient or a new LHHP patient?

Current Patient

New Patient

Second Applicant Membership Category Requested

Wellness

Restoration

Elite Thrive

Vitality

Preferred Payment Schedule For Second Applicant (Choose One Option - If Applicable)

Monthly

Annual

Third Applicant Name (optional)

Third Applicant Date of Birth

Preferred Payment Schedule for Third Applicant (Choose One Option- If Applicable)

Monthly

Annual

Third Applicant Membership Category Requested

Wellness

Restoration

Elite Thrive

Vitality

is the third applicant a current LHHP patient or a new LHHP patient?

Current patient

New patient

Additional Comments/Questions

If you have comments, questions, or additional information that you want to share with us about the applicant(s), please enter your comments/questions/additional information here. We will reply as soon as possible.