THC Initial Patient Intake Form

Membership Care Enrollment

Choose the membership plan and billing option that best fits your needs. After enrollment, you’ll complete your medical intake and schedule your initial visit.
Choose Your Membership Plan
Choose Your Membership Term
Not ready for a membership?

Explore our One-Time Care option for virtual visits and other eligible services.

Click Here to Learn About One-Time Care

Click Here to Start a One-Time Care Visit

Membership Agreement & Payment

Review your selected membership plan and prepaid term below, then enter your payment information securely. Your selected payment method will be charged when you submit your completed enrollment
Your Membership Selection
Selected Membership Plan
Selected Membership Term
Membership Fee
Card Processing Fee (2.9% + $0.30)
Total Due Today
Membership Acknowledgment

Payment Amount

USDDescription

Debit or Credit Card
Credit Card Number	Security Code
Expiration Month	Expiration Year

Patient Information

Please provide your information so we can set up your Membership Care enrollment.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Social Sec # [SECURE]
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Gender
HOME Address

Street Address

Street Address Line 2 (OPTIONAL)
CityStateZip Code
Preferred PHARMACY

Pharmacy Name

Street Address
CityStateZip Code
Emergency Contact Name

First NameLast Name
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.

Medical Intake

Please provide a brief medical history so your provider can review your health information before your initial visit.
Please list any current MEDICATIONS
Please list any current ALLERGIES
Please include REACTION if known
Have you had any of the following conditions?

Other
Please list any SURGERIES
FAMILY medical history (e.g., diabetes, heart disease, cancer)
Is there anything else you want your doctor to know?

Schedule Initial Visit

Choose a convenient time for your initial Membership Care visit.
Appointment

Electronic Acknowledgment and Signature

Please review the complete Totality Healthcare Combined Patient Consent, Urgent Care, Telehealth and Privacy Packet before signing. Your electronic signature applies to the entire packet. Please contact Totality Healthcare before submitting this form if you have questions or are unable to access or retain a copy of the packet.
Combined consent acknowledgment. I confirm that I reviewed the Totality Healthcare Combined Patient Consent, Urgent Care, Telehealth and Privacy Packet, Version 2026.07.1. I voluntarily agree to the consent-to-treatment, urgent and episodic care, pay-per-visit, telehealth, financial responsibility, electronic communication, patient responsibility, emergency-care, and no-guarantee provisions contained in the packet.
HIPAA Notice acknowledgment
Signer capacity
Signer’s Full Legal Name

First NameLast Name
By providing my electronic signature above and selecting Submit, I knowingly and voluntarily adopt this signature as my electronic signature. I intend for it to authenticate this submission and to have the same legal force and effect permitted under applicable law.

I certify that I am the patient or a legally authorized representative permitted to act for the patient; that the information provided is true and accurate to the best of my knowledge; that I was provided access to the complete Totality Healthcare consent and privacy packet; that I had an opportunity to review the packet, ask questions, and request a copy; and that I am signing voluntarily.
I understand that providing my electronic signature above and selecting Submit confirms my present intent to electronically sign this form and accept the applicable terms of the Totality Healthcare consent and privacy packet.
Should be Empty:

Membership Care Enrollment

Membership Agreement & Payment

Your Membership Selection

Payment Amount

Patient Information

Medical Intake

Schedule Initial Visit

Electronic Acknowledgment and Signature