New Patient Appointment Request

Please complete the secure form below. An IHM team member will call you at the number you provide within two business days to schedule a new patient appointment.

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.Format: (000) 000-0000.

What is your date of birth? *

Date

What is your sex?*

FemaleMale

How did you hear about us?*

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 health insurance?*

YesNo

What is the name of your primary insurance company?*

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

PLEASE READ AND ACKNOWLEDGE ALL STATEMENTS BELOW:

Integrative Health Matters is a functional medicine clinic. While some providers may accept patients for primary care, acceptance is based on medical diagnosis, current medications, and alignment with our scope of practice.

In some cases, patients may be asked to maintain their existing primary care provider and utilize Integrative Health Matters as a complementary part of their care. Determination of eligibility for primary care services will be made by the provider during the new patient visit.

Integrative Health Matters providers do NOT prescribe controlled medications.

In general, Integrative Health Matters does not see patients under the age of 18. On a case-by-case basis, patients ages 16–17 may be considered with provider approval.

A current (within one year) mammogram is required for women receiving bioidentical hormone replacement therapy.

Integrative Health Matters providers do NOT treat active cancer.

Integrative Health Matters operates under a collaborative, team-based care model. Patients may be scheduled with and receive services from a variety of qualified care team members, including Medical Doctors (MDs), Family Nurse Practitioners (FNPs), Wellness Consultants, and Health Coaches. While we make effort to accommodate preferences, specific provider requests cannot be guaranteed.

BY SIGNING BELOW, I ACKNOWLEDGE THAT I UNDERSTAD ALL STATEMENTS ABOVE AND WISH TO BE CONTACTED TO SCHEDULE A NEW PATIENT APPOINTMENT.

Signature*