Membership Application


Membership will begin after part 1 and part 2 are complete, and your membership is accepted.

Membership billing will begin on the date that your membership is accepted.

Payment should be made prior to membership services being rendered.

Part 1 Assesses your elligibility for membership 

Part 2 Creates your and your family members accounts in our Medical record 

Part 3 contains PDF forms useful in your care but are not required to start membership:  

You may request a paper copy of the membership application forms from us instead of using this electronic form - see our CONTACT page.


Part 1:   

Family applications only need to complete PART 1 once for the entire family - unless the information is different for any of the members.

After Submitting Part 1, please Click on Part 2 at bottom of the page or navigate back to this Membership application page by scrolling up or down to the selection menu and re-choosing Membership Application.  

Click HERE for Part 1 


Part 2:  

 In Part 2 you will be given an opportunity to complete an entree FOR EACH family member as each one has a separate record.

If you are choosing to list a credit card for AUTO PAY - please pick the date of auto billing closest to your registration date. 

 For example:  If you register on the 13th of the month then billing should be on the 10th.

You do NOT have to enter credit card billing information in this section of Part 2 to register.

In part 3 you will see that we also offer auto Bank deduction & Manual payments by check, cash, bank deduction, or credit card.  This means that you would have to authorize us each time you wish to make a payment to bill your credit card, deduct from your bank account OR you may send us a check or pay in person in cash.  

We do not recommend sending cash by mail.

See Part 3 of this application to choose an option OR

Stop by our office or Contact us to have this set up for you.   

(608) 482-2005 or by email at [email protected]

After you are done with Part 2 then please navigate back to this Membership application page and then go to Part 3.

Click HERE for Part 2


Part 3:

Please Click on each of the forms below to open a PDF file format form for you to print and complete.  

We do need a signature on each of the forms especially the Billing Application form AND the Release of Medical Information form hence why you are not able to complete these online.

THEN return to us in one of the following ways:

Scan signed forms and attach to an email and send back to us at [email protected]

Or Fax signed forms to us at (855) 574-5406

Or Mail back signed forms to us at DIME Medical, 340 Main Street, Darlington, WI  53530

Or drop off the signed forms in person at our office.

1.  Past Medical History form -- gives us your background health history

2.  Billing Application form ​-- enables you to choose how you wish to pay

3.  Release of Medical Information form ​-- allows us to request your medical records from your former doctor.