Please join us for a virtual town hall meeting on Tuesday, July 1st at 6:00 PM ET to learn more about our Personalized Care Program. Please click here to register. If you have any questions, please contact our patient liaison, Elise Stewart at (248) 918-0194 or estewart@signaturemd.com. Thank you.

Concierge Doctor Theodore Shively, DO, Family Medicine in Novi, MI

Personalized Care Program Enrollment

Welcome to my Personalized Care Program. Please make sure information is complete and accurate for each member. If you’re selecting the family plan, you’ll be able to add and remove members below. Your enrollment will be effective today. If you have any questions or need help filling out this form, contact 866.883.8859.

Membership information

Tell us about your membership and payment preferences.

Payment frequency *

Payment method *

Member information

Please make sure all member information is accurate. If you selected the family membership, remember to include all members and each membership level.

*The selected Primary Member will receive all invoices and make all payments for the group.

Primary Member

Prefix

First name *

Middle Initial

Last name *

Suffix

Sex

Date of birth (MM/DD/YYYY) *

Marital status

Email address *

Phone *

Membership type *

Billing address line 1 *

Billing address line 2

City *

State *

ZIP code *

Ensure all required fields are filled in for each member before calculating your Personalized Care Program membership cost. Discounts will be applied when your membership cost is calculated. Total shown will be the total amount of your membership per year, but will be billed per your payment frequency preference.

I agree to the terms and conditions for myself and any additional members.

Full name as signature

Theodore Shively, DO

39555 W 10 Mile Road, Suite 302

Novi, MI 48375

Human.
Health.
Care.