New Patient Request Form
Thank you for your interest in Functional Healing. After submitting this form, our team will carefully review your information. If we feel our office may be a good fit for your needs, we will contact you to discuss the next steps and scheduling options.
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Full Name *
Date of Birth *
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Phone Number *
Email *
What is your address? *
Please Note: Our providers do not prescribe or refill controlled medications, including stimulant medications used for ADHD, or medications requiring ongoing chronic pain management. We encourage patients who require ongoing management of these medications to establish care with a provider who offers those services. *
Required
Are you currently being treated for or have you previously been diagnosed with, any medical conditions by a medical professional?
Clear selection
Please list all medications and supplements you currently take, along with their dosages if available. *
What is your stress level? *
No stress
I am very stressed!
How would you rate your sleep quality?  *
I don't sleep very well
I sleep great!
How would you rate your current energy level on an average day? *
Extremely Low
Very High
What health concerns are you hoping we can help you with? *
Required
How Long Have You Been Dealing With This? *
Have You Seen Other Providers for This? *
Which of these lifestyle factors do you feel contributes most to your current health concerns? *
Required
On a scale of 1-5, how prepared are you to make significant dietary or lifestyle changes to improve your health? *
Not prepared at all
Fully committed
Do you have insurance? *
What Insurance do you have? *
Insurance Policy: Medicare & Medicaid

Functional Healing does not accept Medicare or Medicaid for office visits or medical services. Patients with either of these insurance plans will be considered self-pay and are responsible for all applicable office visit and service fees.

Laboratory Services: Our lab provider, LabTech, can bill Medicare and Medicaid for eligible laboratory services.

Please acknowledge that you understand and agree to this policy before proceeding.

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What is your Member ID number? *
What is your Group number? *
Is your plan HMO or PPO? *

HMO Patients: Please ensure one of our providers is listed as your Primary Care Provider (PCP) with your insurance before your appointment. If this is not updated beforehand, your appointment will need to be rescheduled.

Please note: It is the patient’s responsibility to verify their insurance benefits and provider selection prior to their visit.

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Is the insurance policy under your name or another person’s name? *

If your insurance is not in-network with our office and you choose to proceed as a self-pay patient, the new patient appointment fee is $250, lab reviews are $200, and follow-up office visits are $150, 

Please indicate below if you are comfortable with these fees.

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Due to the high volume of new patients, a valid card on file is required to reserve your appointment. This is our office policy and is necessary in order to schedule and hold your visit.

You may cancel or reschedule up to 48 hours before your appointment without being charged.

Cancellations within 48 hours or missed appointments will result in a $100 late cancellation fee. When an appointment is reserved, that time is held specifically for you and cannot be offered to another patient. This policy helps ensure availability for other patients and respects our providers’ time.

Your card will only be charged in the event of a late cancellation or missed appointment.

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New patient appointments are available Monday–Wednesday, 8:30 AM–3:30 PM. What day and time works best for you? *
Required
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