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 $1,200 and with Dr. Reidhead is $700. 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)Referral
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 Headaches
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 typically send booking confirmation and an appointment reminder via email / SMS. We occasionally send emails regarding company news, updates, special offers etc. You may unsubscribe from these marketing emails at any time. Please confirm you give your permission for :*

I agreeI do not 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