Online Interest Form

At this time eligible patients include:

  • Emory employees and their adult family members covered under Emory's self-insurance program administered by Aetna
  • Aetna Medicare Advantage HMO/PPO members

If you don't meet our pilot program criteria, but are looking for a primary care physician at Emory, please call Emory HealthConnection℠ at 404-778-7777.

If you are eligible to join and are interested in being a patient in the practice, please complete and submit the following information to be contacted by an enrollment specialist. Thank you.**

*First Name:
First Name is required.
*Last Name:
Last Name is required.
* Email Address:
Email is required.Invalid email format.
Please expect a call between 5:00 p.m. and 7:00 p.m.
*Phone Number: ex:404-778-7777
Phone number is required.Invalid phone format.
Alternate Phone Number: ex:404-778-7777
Invalid phone format.
PLEASE NOTE: If submitting this form does not take you to our Thank You page, your information may not have been captured. Please try again or contact an enrollment specialist at 404-778-2050.
* Required

** If your medical problem is an emergency, please seek immediate treatment by calling 911 or visiting your nearest emergency room.

If you don’t meet our pilot program criteria, but are looking for a primary care physician at Emory, please call Emory HealthConnection℠ at 404-778-7777.