Functional Medicine Form

Prior to being scheduled for a consultation with our Functional Medicine specialist, it is required that you complete this form below. Choose the appropriate form based on your gender (Female Intake Questionnaire OR Male Intake Questionnaire) and complete all questions listed.

Once completed, save the completed form to your device and upload the document below in the “File Upload” section. If you are unable to upload the file, the completed form can also be printed and faxed to our office at 716-819-3809 or dropped off in person at the reception desk at our Orchard Park location.

Once all of your information has been received, our office will contact you to schedule your consultation. If you have any questions regarding the required forms, you can contact us at 716-250-2000 x7006

Functional Medicine Forms

Functional Medicine Form Upload

Name *

First

Last

Date of Birth *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Primary Care Provider *

Insurance *

Email *

Confirm Email

File Upload *

Click or drag a file to this area to upload.