Pre-Enrollment Questionnaire
Big Trees MD is a concierge-style Direct Primary Care. We invite all who are interested in becoming a member to complete this questionnaire. At the end of the survey is a link so you can schedule your virtual meet and greet with us in case you have any unanswered questions!
What is your email address?
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What is your first name?
*
What's your last name?
*
What is your preferred or nickname?
What are your pronouns? (e.g., she/they etc.)
How old are you?
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0-1 year
1-18 years
19-41 years
42-64 years
65-99 years
100+ years
What is your preferred method of contact?
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Text
Call
Email
What cell phone number do you use for texting?
*
What is your physical address?
*
Do you have a different mailing address?
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Who Else Needs Care?
Big Trees MD is a full-scope family medicine clinic that cares for families and individuals of all ages.If you would like to enroll your family members in our practice, please provide their information below. If you are not enrolling anyone else, please skip this section.
Family Member #1 (Name, Relationship to you, Preferred Name, Pronoun, Age. Please add Phone, Email, Address if different than yours).
Family Member #2 (Name, Relationship to you, Preferred Name, Pronoun, Age. Please add Phone, Email, Address if different than yours).
Family Member #3 (Name, Relationship to you, Preferred Name, Pronoun, Age. Please add Phone, Email, Address if different than yours).
Family Member #4 (Name, Relationship to you, Preferred Name, Pronoun, Age. Please add Phone, Email, Address if different than yours).
Family Member #5 (Name, Relationship to you, Preferred Name, Pronoun, Age. Please add Phone, Email, Address if different than yours).
Additional Family Members (Name, Relationship to you, Preferred Name, Pronoun, Age, Phone, Email)
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Covid-19 Vaccination Status
COVID-19 vaccines are widely available in the United States. They protect people from getting infected and severely ill, and they significantly reduce the likelihood of hospitalization and death. As of September 9, 2021, one of the COVID-19 vaccines, the Pfizer-BioNTech COVID-19 Vaccine, also known as Comirnaty, has received approval from the Food and Drug Administration (FDA), and two others, the Moderna COVID-19 Vaccine and the Janssen COVID-19 Vaccine, have been authorized by the FDA for emergency use. The FDA has determined that all three vaccines meet its rigorous standards for safety, effectiveness, and manufacturing quality.
Have you been vaccinated against Covid-19?
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Yes
No
When were you vaccinated?
January
February
March
April
May
June
July
August
September
October
November
December
Which vaccine did you receive?
Pfizer
Moderna
Johnson & Johnson
Are there children under the age of 12 in your household?
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Yes
No
Is there anyone else in your household who is not vaccinated against Covid-19?
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Yes
No
Are you interested in receiving a RAPID ANTIGEN COVID-19 test at home?
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Yes
No
Are you interested in receiving a PCR COVID-19 test at home?
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Yes
No
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Insurance Coverage Section
Big Trees MD is a Direct Primary Care clinic. This means that we take care of people no matter if they have insurance or not! We DO NOT ISSUE BILLS TO INSURANCE COMPANIES. However, if you wish to use your insurance to cover other things (like lab tests, mammograms and other imaging studies, prescription medications, and specialist referrals) we may need to send your insurance information with these items. If you are uninsured NO PROB! Just indicate that you don't have insurance in the next question!
Do you have health insurance?
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Yes
No
Who is your insurance carrier?
Medicare
Medi-Cal
Blue Cross/Blue Shield/United/Aetna/Cigna/Etc.
Uninsured
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Would you like to receive vaccinations at home?
Dr. Concepcion is extremely passionate about preventative care. We are working on options for in-home vaccination administration (flu, Covid-19, childhood vaccines, etc.).
Are you interested in receiving your seasonal influenza vaccine (FLU SHOT) at home?
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Yes
No
Are you interested in receiving your Covid-19 vaccine (COVID-19 SHOT) at home?
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Yes
No
Are you interested in receiving childhood vaccines for your kid(s) at home?
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Yes
No
Are you interested in receiving preventative vaccines at your home for adults?
*
Yes
No
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Skin Cancer Screening Program
Through the Big Trees Skin Cancer Screening Program, Dr. Concepcion has the ability to not only track moles and more easily identify which moles have changed, she can also do biopsies if needed. With direct access to Dr. Concepcion, wait times to be seen are same or next day - not the typical months of waiting to be seen in other offices. See BIGTREESMD.COM SERVICES & PRICING for more!
Are you interested in the Dermatology Program?
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Yes
No
Maybe
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Allergy Program
Big Trees MD Allergy Program is making allergy diagnosis and treatment accessible to all! Your allergies can be diagnosed through a simple blood test. Dr. Concepcion can then treat your allergies using sublingual drops (drops you put under your tongue). These drops are MAILED TO YOU and your follow-up visits can be done virtually. No skin prick tests and no driving to the allergist. Members get significant discounts on this program. See BIGTREESMD.COM SERVICES & PRICING for more!
Are you interested in the Allergy Program?
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Yes
No
Maybe
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Patient Billing
Services from Big Trees MD occur on a monthly billing cycle that requires a valid form of payment to be kept securely on file.
What is your preferred form of payment?
*
Bank Transfer / ACH
Debit Card
Credit Card
Venmo
Zelle
Personal / Business Check
Other
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Phew! That part is DONE! Now let's schedule our Meet & Greet!
Is there anything else you'd like Dr. Concepcion to know?
Do you enjoy social media?
Nope!
Facebook
Instagram
Next Door
Pintrest
Snapchat
TikTock
Twitter
YouTube
Other
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Thank you for completing our questionnaire! We're looking forward to meeting you to see if Big Trees MD would be a good fit for you!
Click below to submit your survey!
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