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Want to be a member?

01.

Is NICC's DPC for you? Come talk to us or reach out with your questions!

02.

Fill out the 4 forms below.

You can bring your completed forms to NICC's or email them to us at:

admin@qsaoelxodyojo.com 

03.

We will schedule a visit for you to meet your provider.

We do this to ensure that we are a good fit for you and your family, to answer questions, and learn about your health goals. 

04.

After ensuring that we are a good fit for you and that we will be able to help you meet your health goals, we will charge the enrollment fee and set up your payment plan and you will have access to all the membership benefits.

Membership Application 

Applications are the same just different formats. You only need to select one that is compatible with your device needs.

Printable PDF
 

Fillable Word Doc Form

Retainer Medical Agreement 

PDF

Medical History

There are two versions of this form.  The word document is a tab or mouse fillable form and may be emailed to admin@qsaoelxodyojo.com or completed and printed.

Medical History Form For Printing

Medical History Form Fillable

Consent & HIPPA 

 HIPAA
 

Release Of Records

Upon Completion Of ALL Medical Documents...

You can bring them into the office on your next appointment or email them to our office at