CFFH New Patient Intake Form
Thank you so much for reaching out! The following information will help us determine the best ways to serve you.
* = Required
Patient Name:
*
First Name
Last Name
Patient Date of Birth:
*
Please select a month
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Please select a day
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Please select a year
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Year
Patient Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Email Address:
*
example@example.com
Patient Phone Number:
*
Please enter a valid phone number.
What times of the day are best to call? (You may select more than one.)
*
Morning
Afternoon
Evening
May we leave you voicemail messages that identify the caller as a team member from The Center for Fully Functional Health?
*
Yes
No
Is this appointment for yourself or a child under the age of 18?
*
Myself
A child
If the appointment is for a child, do you have a suspected or confirmed diagnosis of PANS/PANDAS, or is there a different issue?
*
Suspected PANS/PANDAS
Diagnosed PANS/PANDAS
Different issue
We will be in touch to gather further details of your health history, but please begin by providing a brief description of the symptoms and/or diagnosis that bring you to us:
*
How familiar are you with the concept of Functional Medicine?
*
I completely understand the benefits and differences.
I have an idea, but would appreciate more details.
I am unclear about the difference between Functional Medicine and traditional medical care.
Type option 4
Have you ever been under the care of a Functional Medicine physician before?
*
Yes
No
If so, what was the outcome? What else would you like us to know about that experience?
How did you hear about The Center for Fully Functional Health?
*
Healthcare practitioner referral
Friend or family referral
Know Dr. Ellen or Dr. Scott from community interaction
Google or other search engine
Podcast or speaking appearance
Other
If you were referred, whom may we thank for that referral?
If you selected “Other,” please share details:
We consider our work with you a partnership, and we believe passionately in the power of a healthy diet and lifestyle. For some patients, that means making significant diet and lifestyle changes. Is that something you’re willing to do if needed?
*
Yes
No
As part of our partnership, we will also be asking you to make a financial investment in your care. That investment indicates your commitment to our work together and will result in long-term savings, as we eliminate potential medical bills, prescriptions, and time away from work in the future. Are you prepared to make that investment?
*
Yes
No
While we do not accept medical insurance for appointments, we will provide the paperwork necessary to submit your charges to your non-Medicare insurance provider. You may also use HSA, FSA, and CareCredit funds to pay for your care.
Please check the box below to indicate you understand this is the case.
*
I understand
Thank you for taking the time to answer these questions! Our New Patient Coordinator will be in touch within the next 3-4 business days.
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