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.
Email address *
Name (First and Last) *
Your answer
Date Of Birth *
Gender *
Phone Number *
Your answer
Home Address: *
Your answer
Zip Code: *
Your answer
Please select (up to) your TOP 3 health concerns *
Insurance Information
Plan Name: *
Plan Type *
Member ID #: *
Your answer
Never submit passwords through Google Forms.
This form was created inside of Capital Integrative Health. Report Abuse - Terms of Service