Patient Enrollment
Great Plains Family Medicine

Annual fees as set out below shall apply to the following Patient(s), who by signing below agree to the terms and conditions of the GPFM Agreement

____________________________________________________________________________Printed Name Date of Birth (MM/DD/YYYY) Age
____________________________________________________________________________
Street Address City, State, Zip

____________________________________________________________________________
Home Phone Work Phone Cell Preferred Email

____________________________________________________________________________
Spouse Name Date of Birth (MM/DD/YYYY) Age

____________________________________________________________________________
Home Phone Work Phone Cell Preferred Email
Child/Children to Whom this Agreement Applies:

____________________________________________________________________________
Print Name Date of Birth (MM/DD/YYYY) Age
____________________________________________________________________________ Print Name Date of Birth (MM/DD/YYYY) Age
____________________________________________________________________________ Print Name Date of Birth (MM/DD/YYYY) Age
____________________________________________________________________________ Print Name Date of Birth (MM/DD/YYYY) Age

Preferred Payment Method

□ Yearly (Check or Credit/Debit Card) □ Monthly (Credit/Debit Card) □Employer_________
I certify that I have read, understand, and agree to the terms set forth in the Great Plains Family Medicine form. I further certify that I have received a copy of this form.
Signature: _________________________________