Contact Dr. Sam Urick

Reading about Urick Internal Medicine and Dr. Urick on Facebook or online? Interested in learning more?

Before an individual can become a patient of Urick Internal Medicine (Direct Primary Care), Dr. Urick would like to get to know you, explain the “ins and outs” of his practice! We just want to make sure you understand some basic tenets.

If you were a former patient of his, this may save some time! We do offer 30 minute in-person Meet and Greet consultations (if necessary) that can be scheduled at no cost to you! These are non-clinical appointments where no medical problems are discussed and no physical examination is performed.

Complete the form below to contact us! We will be happy to answer your questions!

THE FORM BELOW IS NOT FOR MEDICAL CANNABIS. THIS IS FOR DR URICK'S PRIVATE PRACTICE.

I'M INTERESTED !

Please complete this form if you are interested in joining Dr. Urick's practice. If you are interested in Medical Marijuana - DO NOT COMPLETE this form - you are on the wrong site - visit drsam420.com instead

* Indicates required field

Name *

First

Last

Email Address *

Preferred Phone number *

Date of Birth *

note: Due to insurance regulations, patients with Medicaid or HMO insurance CANNOT become patients in a Direct Primary Care practice. Although Dr. Urick does not accept insurance, those particular plans require that a physician be in-network to cover prescriptions, lab orders, medical imaging orders, etc.

DO YOU HAVE HMO OR PPO INSURANCE ? *

HMO insurance (I must have a PCP listed on my insurance card) PPO insurance (I do not have a PCP listed on my insurance card) Neither of these apply to me I am un-insured

Do you have Medicare, Medicaid OR TRICARE insurance ? *

I understand that My Way Medical does not prescribe controlled medications (e.g. narcotics, stimulants like adipex/adderall, long term benzodiazepines) and I will need to see a specialist for these medications. *

I UNDERSTAND I DO NOT UNDERSTAND

I understand that insurance is NOT accepted as payment (and is not required) and instead I pay a monthly medical service fee for medical visits/services with Dr. Urick *

I UNDERSTAND I DO NOT UNDERSTAND

Dr. Urick believes in evidence based medicine. Patients who choose to work with naturopaths that are not MD/DO physicians will not be a good fit for this practice. I acknowledge that Dr. Urick will work with patients who have an Integrative Medicine physician MD/DO who practices evidence based medicine. For example, Dr. Urick does not ascribe to the belief that "adrenal fatigue" is a medical condition when there is no medical literature to back this up. Dr. Urick does not believe that vitamin infusions will treat/cure cancer. At this point if you do believe in naturopathic medicine, Dr. Urick respects your beliefs but kindly asks that you not submit this form as he does not foresee a working physician-patient relationship. If you are anti-vaccine, Dr Urick kindly asks that you consider finding a physician who shares the same views as you.

Choose One *

I UNDERSTAND DR URICK DOES NOT SUPPORT NATUROPATHIC "MEDICINE" AND WILL NOT SUBMIT THIS FORM AS I WOULD NOT BE CONSIDERED TO BECOME HIS PATIENT

Comment *

Thank you for completing these questions!
It is important to review the "Patient Agreement" on the "HOME" page of this website, the FEE page and FAQ page.

Dr. Urick will be in touch within 1-2 business days to see if Urick Internal Medicine Direct Primary Care (DPC) is right for you!

Please do not list any private health information on this form as it is not HIPAA secure. By clicking "Submit" you accept that comments are not HIPAA secure.

ALSO IF YOU ARE A MEDICAL MARIJUANA PATIENT - DO NOT SUBMIT THIS FORM!!! visit drsam420.com for instructions.

Submit

I'M INTERESTED !Please complete this form if you are interested in joining Dr. Urick's practice. If you are interested in Medical Marijuana - DO NOT COMPLETE this form - you are on the wrong site - visit drsam420.com instead

I'M INTERESTED !

Please complete this form if you are interested in joining Dr. Urick's practice. If you are interested in Medical Marijuana - DO NOT COMPLETE this form - you are on the wrong site - visit drsam420.com instead