Appointment Request Form
Let us know how we can help you!
Full Name
*
First Name
Last Name
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
General Health Information
What brings you to Fountains of Health Primary Care?
General health check-up
Weight management support
Chronic illness management
Preventive care
Other
Do you have any current health concerns or symptoms you’d like to address?
*
Yes
No
Health Goals
What are your primary health and wellness goals?
Lose weight
Manage a chronic condition
Improve overall health
Increase energy levels
Improve sleep quality
Are you interested in any of the following services?
Weight management programs
Nutrition and diet counseling
Stress management
Exercise planning
Other
Lifestyle & Medical History
How would you describe your current diet?
Balanced and healthy
High in processed foods
Focused on weight loss (e.g., keto, low-carb)
Vegetarian or vegan
Other
How physically active are you?
Not very active
Lightly active (e.g., occasional walks)
Moderately active (e.g., exercise 2–3 times a week)
Very active (e.g., daily workouts)
Do you have any known medical conditions or ongoing treatments?
*
Yes
No
Are you currently taking any medications or supplements?
*
Yes
No
Preferences
What is the best way to contact you?
Phone
Email
Text message
Type a question
Type option 1
Type option 2
Type option 3
Type option 4
What date and time work best for you?
Submit
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