Application For Executive Membership

with

Thomas Duncan, MD

First Name

Last Name

Phone *

Email *

1. Why do you want to become an Executive Member at Duncan Integrative Medicine?

2. What are the three most important health goals you hope to accomplish over the next one to five years?

3. On a scale of 1–10, how committed are you to making meaningful lifestyle changes if they are recommended? Please explain your answer.

4. Tell us about a time you made a significant change to improve your health or well-being. What motivated you, and what was the outcome?

5. Our practice is built on a partnership between physician and patient. What does an exceptional physician-patient relationship look like to you?

8. Is there anything else you would like us to know that would help us determine whether our Executive Membership is the right fit for you?

6. Long-term success requires consistency more than perfection. How would you describe your ability to stay committed to healthy habits when life becomes stressful or progress is slower than expected?

7. Executive Membership includes a recurring monthly membership fee for enhanced, non-covered services and personalized access. Are you comfortable with this membership model?

Yes

I'd like more information

Please Select Your Insurance *

Are you open to investing financially in your health beyond what insurance might cover to achieve your goals? *

Yes

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