Omega Direct Signup Form

Mobile Number (SMS ready)*

What is your email address?*

THE CHILD HAS

MEDICAIDPRIVATE INSURANCENO INSURANCE

THIS PACKAGE CAN NOT BE USED WITH ANY INSURANCE. IT IS FOR THE UNINSURED. IF YOU HAVE INSURANCE PLEASE CLICK HERE TO MAKE AN APPOINTMENT WITH US IMMEDIATELY.

Today's date*

DateHourMinutesAM/PM Option

Date of Birth of Patient*

Date

Name of Patient*

First NameLast Name

Gender of Patient*

MaleFemaleOther

Name of Parent or responsible adult*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Select service and pay monthly below*

Direct Concierge($449.00 for the first month then,$239.00 for each month)

New patient sign up includes all of the Prime level services PLUS in-office lab tests, immunization record transfers, unlimited telemedicine visits and direct line to MD - limits apply (BEST VALUE)

Direct Prime($249.00 for the first month then,$159.00 for each month)

New patient sign up plus injections, school forms, sports forms, BUT no immunization records transfers)(MOST POPULAR)

Direct($189.00 for the first month then,$99.00 for each month)

New patient sign up (no injections, no school forms, no sports forms, no letters, no immunization records transfers)

Enter coupon

Total $0.00

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Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

IF YOU WANT TO PAY 3, 6 OR 12 MONTHS ONCE PLEASE CLICK HERE TO MAKE PAYMENT ON DIFFERENT PAYMENT PLATFORM. USE CODE A1139291

The terms of this membership stipulate that I am signing up for a 1 year membership for my child or self.

I may cancel my membership in writing up to 60 days before the annual anniversary date of my registration.
I understand that this Direct Primary Care plan IS NOT health insurance and is not an insurance product, but rather a way to pay for access to the physician care within limits of the services provided at this clinic.
I understand that all our-of-pocket expenses for myself and/or my dependents are due and payable in full at the time services are rendered by Omega Pediatrics providers.
I understand that the only methos of payment accepted by Omega Pediatrics for this service are credit or debit cards (Visa, Mastercard,American Express, Discover). Health savings cards with the Visa/Mastercard logo may be accepted if it goes through when applied online by you on our payment system.
I understand that this service is for patients that do not have and do not plan to present insurance plans to cover the services.
Omega Pediatrics DOES NOT provide superbills for member to file with insurance companies.

As part of this agreement, I hereby authorize Omega Pediatrics to automatically debit/charge my debit or credit card every month on the day of the month that matches my membership effective date.

I understand that notice of termination must be received in wrtiting 60 days in advance in order for this authorization to be terminated.

Signature*

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Omega Pediatrics Direct Primary Care Application