Core Membership

First Name of Member *

Last Name of Member *

Phone Number of Member *

Email of Member *

Full Name of Payor (if different than member name)

By checking this box, I consent to receive non-marketing text messages from AMS Lifestyle Medicine and related companies. I understand that text messaging is not HIPAA compliant and will use the patient portal for care. Message frequency varies, message & data rates may apply. Reply STOP to opt out but please check your email as we will not be able to text you.

By checking this box, I consent to receive marketing and promotional messages including special offers, discounts, new product updates among others, from AMS Lifestyle Medicine and related companies at the phone number provided. Frequency may vary. Message & data rates may apply. Reply STOP to opt out.