Membership Application | DoctorNYC Concierge Medicine

Section 01

Personal Information

Your basic contact details. All information is strictly confidential.

First Name *

Last Name *

Email Address *

Phone Number *

Date of Birth *

Biological Sex

Home Address

Section 02

Membership Tier

Select the tier that best reflects your needs. Our practice manager will review this during your introductory consultation at 910 Park Avenue. Membership investment details are shared privately.

Preferred Membership Tier *

The Foundation

Unlimited same-day appointments · Direct physician access · Annual wellness exam · Labs included

The Signature · Most Selected

All Foundation benefits · Priority 24/7 access · Quarterly reviews · Longevity panels · Executive assessment · In-home visits available

The Private

All Signature benefits · Full family coverage · Travel medicine · Specialist network · Hospital coordination · Dedicated care team

I am not yet certain — please advise

Our practice manager will discuss tier options during your introductory consultation

Section 03

Your Health Goals

Understanding what matters to you helps us determine how DoctorNYC can serve you most effectively.

What are your primary healthcare priorities? Select all that apply.

Preventive care & disease prevention Longevity & healthspan optimization Management of an existing or chronic condition Executive health & performance 24/7 physician availability & peace of mind Family care coordination Access to specialist & hospital coordination

In your own words, what do you hope to achieve with DoctorNYC membership?

Section 04

Logistics & Referral

A few final details to help us prepare for your introductory consultation at 910 Park Avenue.

How did you hear about DoctorNYC? *

If referred, by whom?

When would you ideally like to begin? *

Preferred method of contact *

Anything else you would like us to know?

Section 05

Consent & Confirmation

I have read and agree to the Privacy Policy *

I consent to being contacted by DoctorNYC regarding my application *

I confirm that all information provided is accurate and complete *

Your application is reviewed personally by our practice manager.
You will receive a response within two business days.

✓

Application Received

Thank you for applying to DoctorNYC. Your application has been submitted and is now under personal review by our practice manager.

We will be in touch within two business days to discuss next steps. You may also reach us directly at membership@doctornyc.com.

910 Park Avenue · New York, NY 10075