Polaris Integrative Functional Health & Weight Loss Patient Information

Polaris Integrative Functional Health & Weight Loss
Patient Information
Full Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Sex at birth

FemaleMale
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Insurance or Self Pay:*

InsuranceSelf Pay
Insurance Information
Insurance Carrier:
Member ID:
Group Number:
Primary Care Physician:
Front of Insurance Card
Back of Insurance Card
Procedure/Service Requested*
(e.g., primary care, weight loss, hormone replacement therapy, labs, medications, specific tests, procedures)
Date and Time of Appointment
Card Details

This information will be securely stored in our records. Your card details are protected, and you will not be charged without your prior knowledge or authorization.
Card Number
Expiration (MM/YY)
Card Code (CVV2/CVC2/CID)
Type of Appointment

In-clinicVirtual
All initial appointments are conducted virtually, and follow-up visits can be either virtual or in-person at the clinic.
Should be Empty:

Polaris Integrative Functional Health & Weight Loss