Rejuvenate Integrative/Functional Medicine Interest Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Best way to reach you:

Best time of day/time of day to reach you:

What programs are you most interested in learning more about?

Other

Are you prepared to make lifestyle changes (diet, movement, stress reduction,etc) necessary to fullfill your prescribed plan?

I understand that all paperwork must be completed a minimum of 48 hours prior to my initial appointment. This allows our provider to review all information and permits the maximum benefit of the appointment to develop your goals and plan of care.

I understand that the cost of my program will depending on any testing/medication/supplements/treatments that may be recommended and agreed upon.

I understand that this program is completely voluntary in nature and at no time am I obligated to obtain any testing/medications/supplements/treatments.

I understand that my refusal to get recommended testing/medications/supplements/treatment may impact the ability of my provider to deliver the full scope of my care.

Please include any other pertinent information that will assist us in contacting you to set up your initial consultation:

Thank you for taking the time to request your appointment. We will be reaching out to you within the next 2-3 business days to set up your initial consultation.

If you have any questions in the meantime please call our office @ 641-218-0609.

Thank you, we look forward to meeting you and assisting you on your health journey!