Informational Call Scheduling Form

Please select a time for your informational call and complete the information below. The information allows us to be prepared for the call. We will call you at the number provided. *
Informational Call Scheduling Form
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell phone number*
Please enter a valid phone number.
What is your date of birth? *

MonthDayYear
Date
What is your sex?*

FemaleMale
How did you hear about us?*

A friend or family member recommended IHM!Facebook/InstagramTV CommercialGoogle SearchOther
Do you have a current primary care provider?*

YesNo
Who is your primary care provider?
Are you looking to establish a new primary care provider?*

YesNo, I'm happy with my current primary care provider.
Why do you want to become a patient at Integrative Health Matters? *
Briefly, what are the main health concerns you are hoping a functional/integrative medicine approach will improve? *
Please list all your current prescription medications. (You do not need to list vitamins and supplements). *
Do you have medical insurance?*

YesNo
What is the name of your primary insurance company?*

MedicareBlue Cross Blue ShieldAetnaUnited HealthcareHumanaCignaOther
What is your member or subscriber ID listed on your insurance card? *
What is the group number listed on your insurance card? *
What is the Medicare number listed on your Medicare card?*
Do you have a supplemental policy? (A policy that often picks up what Medicare doesn't pay?)*

YesNo
What is the name of your supplemental policy? *
What is the member or subscriber number on your supplemental insurance card?*
Which type of insurance policy do you have?*

PPOHMO (HMO policies are not accepted, but we have Cash Patient Options)EPOOther
Integrative Health Matters is a functional medicine clinic. IHM providers do accept some patients for primary care and acceptance is dependent on medical dx, medications and practice scope.

Some inquiring patients may be asked to retain their current primary care provider and utilize the IHM team as an adjunct to their care.

IHM providers do not prescribe controlled medications and acceptance for primary care will be determined by the IHM provider during new patient appointment.

In general, IHM providers do not see patients under 18 years of age. On a case by case basis, some patients age 16-17 may be accepted with provider approval.

By signing below, I agree that I have answered all questions truthfully to the best of my ability.
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