Appleton Clinics GJ, LLC Patient Portal

Join Us

Enrolling in Appleton Clinics is quick and easy using this secure form

  • If you prefer, call (970) 985-7110 to speak with an enrollment specialist and enroll over the phone or in person.
  • Each adult membership is $79 per month, collected automatically from your credit or debit card.
  • Adult members may add up to two children 25 & under free per family.  Additional children are only $10 per month each.
  • A one-time $99 registration fee per adult will be included in your total initial charges.
  • You may cancel at any time.

We do not deny membership for pre-existing conditions or lack of insurance coverage.  Clinic space is limited.  Once you submit this application and complete your medical history form(s) we will contact you if we have any questions or concerns about our physician’s ability to properly care for you given your particular healthcare needs and our current patient capacity.  If for any reason your membership is not accepted, we will refund your $99 enrollment fee(s).

Basic Contact Information

Home Address

Contact Information

Emergency Contact

Set Username and Password for Patient Portal

To gain online access to your medical records and secure communications, please create a username and password that you will use to log into the patient portal in the future.

  • Your username must be at least 4 characters long.
  • Each participating member on your account must have a unique username and password.

Your password must be at least 8 characters long and include at least one number or special character.

Billing

Credit/Debit card monthly auto-payment required for membership fees.

Card Details

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Card Billing Address

How did you hear about Appleton Clinics?

Authorization

On behalf of all of the members on this account, I understand and agree to the following (read and check all items indicating your acceptance):

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