New Patient Health History
Welcome to Integr8 Health!  We look forward to the opportunity to serve you.  Thank you for taking the time to complete our intake and consent forms. 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.**
**If a question does not apply, please write "n/a" to allow you to skip to complete and submit the form.**
Sign in to Google to save your progress. Learn more
Email *
First name *
Last name *
Date of Birth *
Mailing Address *
City *
State
Zip Code *
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, Hormone consultation, Well care visit, Hypnotherapy, Reiki, Osteopathic Manipulation Therapy.  
Do you have a preferred provider request??  *
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Integr8 Health.

Does this form look suspicious? Report