myGAdoctor Individual Family Group
Flat Fee Medical Membership
Click Here to Join Now!


Join Us No Medical Underwriting

The medical membership plan provided by
My Georgia Doctor is not health insurance
and is not intended to replace health insurance.

To apply for a My Georgia Doctor membership, please complete the form below. If you would rather mail in your application, please click here for a printable application.

Title: First Name*: Last Name*:
Your Contact Info:
 Phone Number*:
( ) -  
E-mail Address**:

(If you don't have an e-mail address please leave this field blank)
Street Address*:

City*: State*: Zip*:
Gender*: Male Female  
Date of Birth*:  (MM/DD/YYYY)
How did you hear about us?
My Georgia Doctor Membership
Please Select a Membership Type and Payment Option:
 1. Individual 
Payment Option:
 2. Family (Up to 10 Individuals)
Payment Option:
Member 1:
Male Female   Birth Date:  (MM/DD/YYYY)
Member 2:
Male Female   Birth Date:  (MM/DD/YYYY)
Member 3:
Male Female   Birth Date:  (MM/DD/YYYY)
Member 4:
Male Female   Birth Date:  (MM/DD/YYYY)
Member 5:
Male Female   Birth Date:  (MM/DD/YYYY)
Member 6:
Male Female   Birth Date: Calendar  (MM/DD/YYYY)
Member 7:
Male Female   Birth Date: Calendar  (MM/DD/YYYY)
Member 8:
Male Female   Birth Date: Calendar  (MM/DD/YYYY)
Member 9:
Male Female   Birth Date: Calendar  (MM/DD/YYYY)
Member 10:
Male Female   Birth Date: Calendar  (MM/DD/YYYY)
Requested Effective Date
Please enter when you would to start the program:  (MM/DD/YYYY)
Promotion Code
Please enter your Promotion Code if you have one:
Payment Information (This page is SSL Secured using 128 Bit Encryption)
Please Select a Payment Type:
 1. Credit Card/Check Card
Payment Type:
Credit Card #:
Credit Card CVV2:
(3 digit number on the back of card. 4 digit number on front for AmEx)
Expiration Date:
Name on Card:

Billing Address:
City: State: Zip:
Member Agreement ( Printer-friendly version )
Please check the box below:
I agree to the following:
        •  I accept the Membership Agreement above.
Please verify the information you entered is correct and then click Sign Up. Please wait a few seconds after you click so we can process your order.
This is NOT Insurance

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Proud Member of:
My Georgia Doctor, Inc., Health & Medical  General, Norcross, GA