Dr. Highley CirrusMED Transition Form - Preferred Family Medicine

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Dr. Highley CirrusMED Patient Transition Form

For patients transitioning from Dr. Highley's CirrusMED platform to Preferred Family Medicine. Must be a resident of Nevada, California, Hawaii, or Florida.

Name

This field is for validation purposes and should be left unchanged.

Name(Required)

First Last

Date of Birth(Required)

Email(Required)

Phone(Required)

Preferred Method of Contact(Required)

Phone

Text

Email

Address(Required)

Street Address Address Line 2 City State Zip

Were you previously a CirrusMED patient of Dr. Christopher Highley?(Required)

Yes

No

Not sure

I am interested in:

Continuing virtual care with Dr. Highley through Preferred Family Medicine

Learning more before enrolling

Are you comfortable using an online patient portal?

Yes

No

Preferred appointment type

First available telehealth visit

I would like your team to advise me

I am only requesting information at this time

Insurance acknowledgment(Required)

I understand this program is a direct-pay service and is not billed to insurance.

Enrollment acknowledgment(Required)

I understand that completing this form does not establish a physician-patient relationship until accepted and scheduled by the practice.

Communication consent(Required)

I consent to be contacted by phone, text, and/or email regarding my inquiry and enrollment.

Privacy acknowledgment(Required)

I understand this form is for initial enrollment and coordination purposes and that additional intake, consent, and medical forms may be required before treatment.

Signature(Required)

Date Signed(Required)

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All rights reserved | Preferred Family Medicine® | Copyright 2026 | This practice does not constitute insurance. This practice provides only the limited scope of primary care as specified in the retainer medical agreement. Specialty and/or hospital care, pharmaceuticals, and testing (labs that are not included, X-ray, Ultrasound, etc.) are not covered by your fee and are your financial responsibility.