New Patient Health History
Welcome to Integr8 Health, and thank you for taking a couple minutes to complete our intake and consent forms. We look forward to the opportunity to serve you. The information you submit in this HIPAA-secure form is protected health information and will be used only by this office unless you provide a written release. **Please do not use use your auto-fill function, it creates a problem for some users that prevents advancing and completing the form**

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Email *
First name *
Last name *
Date of Birth *
Complete Address INCLUDE CITY, STATE, and ZIPCODE *
What is your gender *
Primary phone *
Secondary phone
Emergency contact name, relationship, and phone number *
Please tell us what services you are seeking assistance with. Also include if you feel you may be interested in other services we provide.  (Ketamine consultation, cannabis certification consultation, functional medicine, Lyme consultation, Well care visit, Hypnotherapy, reiki, Osteopathic Manipulation Therapy.  
Do you have a preferred provider request??  *
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