NEW PATIENT QUESTIONNAIRE

Thank you for your interest in becoming a new patient at VIDA Integrative Medicine. As part of our “integrative medicine” approach, we strongly believe in partnering with our patients on the journey to good health. If that sounds like the sort of relationship you would like with your healthcare provider, please tell us a little about yourself.

We’ve created a simple online form for you to communicate with us in a secure and confidential manner. We try to respond to all new patient requests within 3 business days (feel free to call if you haven’t heard back from us within a week).

Please be advised that by using this form to contact our office, we are not confirming an appointment nor establishing a physician-patient relationship. As a user of this mode of communication and of our website, you assume all risks with placing confidential information into this portal. This form of communication is not intended for acute, emergency, or life-threatening health conditions. If you believe you are having a health emergency, contact 911 or go to your nearest emergency department.

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Nameyour full name
DOBmm/dd/yyyy
Current Insurance
Member ID#(from insurance card)
Insurance ID#(If different from member ID)
Any expected changes in your insurance coverage in the next six months?
Detailsif yes
0 /
Name of your current employer?
Do you need to be seen immediately?
Reasonif yes
Which provider are you wanting to establish care with?
Functional Medicine
Family Practice
Acupuncture
Pain Management
GYN
Please list any other family members that you want to establish care for:
Please list all ongoing medical issues?
0 /
Please list all current medications including any you are taking for chronic pain
0 /
How did you hear about our clinic?
Please list the best contact # for you
Please enter your e-mail address
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