New Client Consultation Form

New Patient Consultation Form

The following information will be used to help plan a safe and effective treatment. All information will remain private & confidential.
Please note: we are a cash-based practice and require payment via cash, debit, or credit card at the time of service. Initial 2 hr consult with Dr. Fox is $1,600 and with Dr. Reidhead is $800. If applicable, we will use your insurance for any diagnostics or testing that is needed.*

I acknowledge the above statement
General Information
Name*

First NameLast Name
Today's Date*

MonthDayYear
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?

Google / Online SearchSocial (Instagram / Facebook)ReferralOther
Date Of Birth*

MonthDayYear
Date
Tell us about yourself
Tell us a bit about your health and what you would like to work on.*
Which symptoms are you experiencing? Check all that apply.*

FatigueInsomniaGut DysfunctionMold ToxicityLyme & Co-InfectionsHormone ImbalancesMigraines or HeadachesOther
Have you worked with a functional medicine doctor before?*

YesNo
How soon do you need to be seen?*
Are you interested in optimizing your Health & Longevity?*

YesNoUnsure
Are you interested in IV Nutritional Therapy?*

YesNo
Is there any other information you would like to make your physician aware of? If yes, please provide details.
Disclaimers
Reservation & Cancellation Policy for all current and future appointments: In the event of cancellations received less than 48 hours prior to appointment a cancellation fee equal to the reserved service booking will incur. No Shows will be charged 100%.*

I understand the reservation and cancellation policies
GDPR Statement: In accordance with the General Data Protection Regulation, this information will be held securely by Boulder Holistic for 8 years. This is standard practice and is required for insurance purposes. Please note, your personal data will remain confidential and will never be shared with a third party without your written consent. If you wish to see the data on your files, please request in writing via email to contact@boulderholistic.com. Please confirm that you have read and agree with this statement.*

I agree that my information will be held securely in compliance with GDPR requirements.
We may send booking confirmation and appointment reminders via email and or SMS. By submitting this form, you agree to receive SMS and/or emails from Boulder Holistic. You may unsubscribe by replying "STOP" at any time or by following the instructions provided in our communications. Please refer to our Privacy Policy for more information: https://boulderholistic.com/privacy-policy/. Please confirm you agree to these terms by checking the box below:*

I agree
Thank you for taking the time to complete this form - our team will review your information and reach out to schedule your New Patient appointment shortly.

Boulder Holistic
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New Patient Consultation Form

General Information

Tell us about yourself

Disclaimers