Integrative Health Institute Prospective Patient Form
Please confirm your Full Name
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First Name
Last Name
Please confirm your Email Address
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Confirmation Email
example@example.com
Please confirm your Phone Number
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Please enter a valid phone number.
How did you hear about us?
Are you looking for a Functional Medicine Provider?
Have you reviewed our website and are you familiar with what a private Functional Medicine practice can help you?
What health symptoms, if any, do you have that you want to resolve? If none, please let us know why you are looking for a Functional Medicine doctor.
What has been your biggest obstacle to fixing your health concerns or health goals?
Briefly tell us what you are doing right now to fix this problem? or Briefly tell us what you are doing to work on your health care goals right now.
How long have you been struggling with this problem? Or if you do not feel that you have any, any you are healthy, just type I'm Healthy.
Right now I …
Have the financial resources to invest in my health?
Have access to the financial resources to invest in my health?
I do not have the financial resources to invest in my health and I am going to stay exactly where I am
If someone asked me to spend money on my health, I would...
Know that its what any seriously ill person suffering from breast implant illness would do to solve this problem
Would be a little intimidated but, with a proven system I would do it, because I am serious about solving this problem
Avoid it at all costs because I cannot afford to invest in my health
If I needed to participate in my health concerns, I would...
Be willing to change what types of food I eat and supplements recommended to me, because I want to get better
Be willing to change what types of foods I eat and take supplements recommended to me if you could show me why I needed to change
I am not willing to change the types of food I eat or take supplements, because I do not think that will help me
Our office is currently returning calls for New Patient enrollment in 4-6 weeks. We apologize for this inconvenience. Someone will call you when we have a New Patient Appointment available with Dr Bryan Glick. If you need to see a physician before this time, please call your primary care doctor. Please confirm by typing “Yes I will” in the box below.
Finally, on the scale of ONE to I AM HEALTHY, how committed are you to you?
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