Whole Medicine Intake Form

I understand that Dr. Harding does NOT provide primary care services. She sees patients for functional medicine consultations. I need to maintain a relationship with a primary care physician to manage acute/emergency issues, routine screenings, and annual physicals.*

I understand and acknowledge
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
May we leave voicemail messages that identify the caller as a team member from Whole Medicine?*

YesNo
How did you hear about Whole Medicine/Dr. Kristen Harding?*

Friend or family referralHealthcare practitioner referralInternet searchInstitute for Functional Medicine websiteOther
Is this appointment for yourself or a child under the age of 18?*

MyselfA Child Under 18
If it is for a child under 18, what is your name and relationship?
Please provide a brief description of the symptoms and/or diagnosis that brings you to us (a more complete health history will be gathered in the future):*
How familiar are you with the philosophy of Functional Medicine?*

I don’t really know what Functional Medicine isI have an idea, but could use some more details about this type of careI completely understand the benefits of Functional Medicine and how it differs from conventional medical care
Have you been under the care of a Functional Medicine physician previously?*

YesNo
If so, what would you like us to know about that experience?
Functional Medicine is an approach to health that often requires significant diet and lifestyle changes. Is this something you are ready and willing to do?*

YesNo
Because Functional Medicine care takes significant time beyond what conventional medicine provides, we do not contract with any insurance companies, Medicare or Medicaid. This means that you pay the cost of your healthcare directly. This is an investment in healing and in your future health. Are you prepared to make that investment?*

YesNo
I understand I am responsible for paying the cost of health care directly, and have reviewed the pricing information listed in the 'How It Works & Pricing' section of the website: https://www.kristenhardingmd.com/pricing

Yes, I understandNo
While we do not accept medical insurance for appointments we will provide the paperwork necessary to submit your charges to non-Medicare insurance providers so you can seek out-of-network reimbursement on your own. There is no guarantee that your insurance will provide any reimbursement and the office will not submit any paperwork on your behalf beyond giving you the superbill receipt with required codes at the end of each appointment. Please indicate that you understand this policy.*

Yes, I understand
We would like to set up a brief discovery call where we will discuss your health concerns, as well as Dr. Harding's approach to providing care. Please select a 15 minute time slot for our Health Coach to call you.*
In order to best serve her patients, Dr. Harding accepts a limited number of new patients each month. This allows her to provide personalized and in-depth care for her current patients. Her goal is to help patients on their path to healing and to give them tools to continue to stay well in the future.

We thank you for your interest and will be in touch by email within five business days about current availability or wait-list time expectations. Please add info@kristenhardingmd.com to your contact list so our email does not get lost in your spam box.
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