Remote Primary Care Screening Request

This short screening request is for North Carolina adults 18+ interested in remote direct primary care. We review each request before accepting a membership or scheduling an initial visit. Please do not include detailed medical information. This remote membership does not provide chronic pain management, and controlled medication prescriptions or refills are not guaranteed.

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Full Name *

Phone Number *

Email

What North Carolina city and county do you live in? *

City and county only. Please do not include your street address.

What are you looking for help with through remote primary care?

A brief, general description is enough. Please do not include diagnoses, medications, or detailed medical information here.

Are you age 18 or older? *

• Yes
• No

Do you have access to a local lab and all four home tools? *

• Yes, I have local lab access and a BP cuff, pulse oximeter, thermometer, and scale
• I can arrange a local lab or obtain the tools before enrollment
• No, I do not have access to these

These are required for remote membership.

If an in-person exam or test is needed, can you arrange care near home or travel to Asheboro? *

• Yes
• I would need help planning that
• No

Which best describes the care you are seeking? *

• Ongoing routine primary care and follow-up
• Several complex needs or frequent hands-on care
• Care for a new urgent or emergency concern

Are you currently taking any controlled prescription medications? *— Select Choice —NoYesI prefer to discuss this by phone

This helps us plan a safe fit. Remote membership does not guarantee a prescription or refill.

If yes, which controlled medication(s) do you currently take?

Medication names only. No doses or medical history here. You may leave this blank if you prefer to discuss it by phone.

Send My Request

Remote care is not for emergencies or needs that require frequent hands-on care. If you need urgent care, seek local help; for an emergency, call 911.