New Patient Interest Form X/TwitterThis field is for validation purposes and should be left unchanged.Name(Required) First Last PhoneEmail(Required) Your Health HistoryWhat is your main health concern?(Required)Are you interested in functional medicine or just looking for a new primary care practitioner?(Required)Have you ever seen an alternative, integrative, or functional medicine provider?(Required)YesNoPlease tell us about your experienceHave you had any previous testing (conventional or functional)?(Required)Examples: blood work, imaging scans, stool testing, genetic testing, hormone panelsWhat is your past medical history and/or diagnoses you have received?(Required)What are your expectations for your health journey?(Required)Insurance & Lab WorkHow would you like to handle lab work?I'll use my insurance for lab workI'm interested in discounted self-pay lab optionsNot sure yet / Need guidance on thisAdditional Questions or Comments(Required)What Happens After You Submit Our team reviews your intake form We'll contact you by phone or email to schedule your first appointment You'll receive a welcome packet with everything you need to prepare Δ
