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

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.

If you are human, leave this field blank.