Harris Family Health
Enrollment Intake Form!
Start your HFH enrollment here! Check your email for more enrollment information!
*
indicates required
Name:
Email:
Comment:
First Name
Last Name
Email Address
*
Phone Number
(
)
-
for enrollment purposes only
Are you interested in enrolling yourself today?
Yes
No
Are you interested in enrolling additional people?
Yes
No
Where Did You Hear About Harris Family Health?
Internet Search
Family Member or Friend
Referral from Patient
Facebook
Instagram
LinkedIn
Community Event
Flint Courier News
Other
Do you have health insurance?
Yes - Non-Medicare Insurance
Yes - Medicare Insurance
No Health Insurance
HFH Membership Status
Previous Enrollment Interest
Not Enrolled
Enrolled
Enrolled - Special Messages Only
