Register as a New Patient
Please fill out the following info in order to register as a new patient, so that we may learn more about you and your general medical needs. As soon as one of our Wellness Coordinators gets you set up, you will receive a link prompting you to set up your Patient Portal. In the portal, you will find a Health History and our Consent forms that need to be completed before you schedule an appointment and additional directions for your next steps. Thank you.
Name (First and Last)
Date Of Birth
Prefer not to say
Please select (up to) your TOP 3 health concerns
General Check-up/Integrative Primary Care
Well woman's exam: Pap smear, Breast Exam
Gut Concerns (reflux, gas/bloating, diarrhea/constipation/irritable bowl syndrome, IBD, Crohn's, ulcerative colitis)
Energy/Mood (fatigue, insomnia, anxiety, depression, ADD/ADHD)
Pain: chronic (e.g. arthritis, fibromyalgia, tendinitis, etc.)
Cardiometabolic (high blood pressure, weight control, diabetes/blood sugar, heart disease)
Hormone Balance (Adrenals/Thyroid)
Hormone Balance (Sex Hormones, Considering Bio-Identicals)
Lyme or other infections
Cancer prevention and/or treatment
Toxicity/detox, e.g heavy metals, mold
Member ID #:
Page 1 of 1
Never submit passwords through Google Forms.
This form was created inside of Capital Integrative Health.
Terms of Service