Procedure Intake Form

This form is for patients interested in IV Ozone Therapy, PRP, Trigger Point & Joint Injections, Hair Restoration, and Musculoskeletal Consults. If you you interested in being seen for Functional Medicine or for full medical evaluation, please return to our website and complete the Adult or Pediatric Intake Form.

We hope you will answer the questions on this medical history form as thoughtfully as possible. Please consider this an opportunity to write anything you think may be pertinent to your condition. ALL THE INFORMATION IN THIS QUESTIONNAIRE IS CONFIDENTIAL BY LAW.

If you do not have all your X-rays, MRIs, CT Scans (both images and reports), please start collecting those from other providers you have seen. They are vital in guiding you appropriately.
Today's Date*

MonthDayYear
Date
What is your name?*

First NameLast name
Date of Birth?*

MonthDayYear
Your date of birth
Gender Identity?
M/F/transgender M/ transgender F/decline to specify
Preferred Pronoun(s)
Nickname
What is Your Home Address?

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What is your phone number?*
Email address?*
Email Address
Emergency Contact: name and phone
Please pick smoking status from drop down menu
How did you hear about us?*
Which Procedure Would You Like To Schedule?*

Ozone TherapyHair ResorationMusculoskeletal ConsultPRP (with or without Ozone)Other
What is the reason for today's visit? Please include when any problems began. Be sure to include dates of consultations with other providers, x-rays, MRIs. Please include as many details about your condition as possible, even if it seems unimportant.*
Height
Weight
Allergies to Medication? Please include what reaction you have.
Allergies to Foods?
Current Medications and Supplements including condition you take them for:
Please list name, street address (including zip code), and phone number of your preferred PHARMACY for PRESCIPTIONS. *This will be saved to your chart*
I hereby certify that the above information is true and accurate to the best of my knowledge.
The Functional Medicine Center may contact me via SMS (Text Message) in response to my form. Privacy Policy is available to review at https://thefunctionalmedicinecenter.org/privacy-policy. By checking this box, you agree to receive SMS from The Functional Medicine Center
Please sign your name with attached stylus or mouse if completing at home. All data on this form is encrypted and is transmitted securely via SSL.*
Should be Empty: