Harmony Medical Concierge — New Patient Enrollment

Direct Primary Care

Harmony DPC Membership

Your personal physician, available when you need them — no copays, no waiting rooms.

$50 / month

No contracts · Cancel with 30 days notice

Unlimited office visits — no copays
Same-day & next-day appointments
Direct phone & text to your physician
Preventive care & annual wellness exams
Chronic disease management
Lab coordination & specialist referrals
Telehealth visits included

About You

Contact

Medical

Consent

Payment

Welcome to Harmony!

HMC-XXXX

Your membership is active and your patient chart has been created. Check your email for the next steps.

📋 Please check your email

We sent forms to that must be completed before your first visit:

• HIPAA Notice of Privacy Practices
• DPC Membership Agreement
• Patient Intake & Medical History
• Financial Agreement

Tell us about yourself

This information will be used to create your patient chart at Harmony.

First Name * Required.

Last Name * Required.

Date of Birth * Required.

Sex at Birth * Required.

Preferred Language

Marital Status

Contact information

We'll use this to send your forms and reach you about appointments.

Email Address * Enter a valid email.

Phone Number * Required.

Street Address * Required.

Apt / Suite

City * Required.

State

ZIP Code

Emergency Contact

Contact Name

Relationship

Emergency Phone

Medical background

A brief overview so Dr. Hernandez is prepared for your first visit. You'll complete a full intake form by email after enrolling.

Reason for joining Harmony

Active Medical Conditions

Current Medications & Dosages

Known Allergies * Please list allergies or write NKDA.

Tobacco / Smoking

Alcohol Use

Prior Surgeries

Previous Primary Doctor

Authorization & consent

Please read and acknowledge the following before completing enrollment.

HIPAA Notice of Privacy Practices

Harmony Medical Concierge & Wellness Studio is committed to protecting the privacy of your health information (PHI). We use your information for treatment, payment, and healthcare operations — including appointment reminders, coordination with specialists, lab results, and referrals.

Your rights: You may request access to your records, request corrections, and request restrictions on how your information is used. Contact us anytime at (407) 961-9638 or info@harmonymedicalconcierge.com.

Membership: By enrolling, you authorize a recurring $50/month charge. Cancel with 30 days' written notice.

I acknowledge receipt of the HIPAA Notice of Privacy Practices for Harmony Medical Concierge & Wellness Studio.

I consent to treatment and authorize use of my health information as described. All information provided is accurate to the best of my knowledge.

I authorize a recurring monthly charge of $50.00 for the Direct Primary Care membership, cancellable with 30 days' notice.

(Optional) I consent to receive appointment reminders and health updates via SMS and email.

Digital Signature

Full Legal Name * Your signature is required.

Date

Relationship to Patient

Membership payment

Your first $50 is charged today. Your membership renews monthly on the same date.

Harmony DPC Membership

Billed monthly · No contracts

$50.00 / mo

Card Number, Expiry & CVC

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By clicking above you authorize a recurring $50/month charge. Cancel anytime with 30 days' notice.