New Patient Inquiry

New Patient Inquiry

Complete the form below to request your first appointment. This form is HIPAA compliant and all information collected is treated accordingly. If you have any questions, please reach out to newinquiries@dcimedicine.com
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
How did you find out about DCIM?
If you selected "Other" above, please specify
What is the main reason you want to see a doctor at DCIM?

0/150
Are you interested in psychiatric services? If so, please explain.

0/150
Are you interested in receiving psychiatric services from DCIM? [Note: At this time, DCIM is no longer accepting new psychiatry patients.]
Please specify in which psychiatric services you are interested. Feel free to select more than one.

Other
Please discuss/summarize relevant medical history.

0/150
Have you seen a Functional or Integrative Medicine doctor before? If so, please provide practice name and doctor name.

0/150
Please indicate your sex
If you prefer to describe your sex differently, please enter your answer below
Dr. Dsouza periodically runs a small group for women, Optimizing Your Metabolic Health. Since registration often fills quickly, would you like us to send you a priority notification about it?
Dr. Dsouza periodically runs a guided functional medicine detox group for women. Since registration often fills quickly, would you like us to send you a priority notification about it?
Please take a moment to look at our website for additional information about our practice, including information about DCIM's approach and process. Please note that DCIM does not accept insurance, although we will provide you with the necessary paperwork for you to seek reimbursement, if applicable.
We will use your email to send updates about the practice and other information (hours, closures, etc).
Solely Telemedicine?
Should be Empty: