Your Contact Information

Who is this application for?

For Me

For a Dependent

First Name *

Last Name *

Phone *

Email *

Previous Experience

Are any of your family members active members with Richmond Integrative & Functional Medicine? *

Yes — I am an active member with RIFM

Yes — Someone else in our family is a member.

No — No one in our family is an active member.

Have you previously worked with any of our providers? (Check any that apply) *

Dependent Information

First Name *

Last Name *

Age *

Does your child have a phone number you want added? *

Yes

Does your child have an email you want added? *

Yes

Health Insurance Information

If you dont have a standard health insurance plan, how would you intend to pay for office visits? *

Pay with cash

Group sharing plan

Membership with RIFM is still possible without health insurance, but would require paying for visits and any labwork out-of-pocket.

Health Insurance Information

Do you have a standard health insurance plan? *

Yes

Health Goals

What would you like your health to be in 3 months from now? How about 6 months from now *

If we were to work together what would you expect to achieve from working with us? *

Your Current Health Condition

How many chronic health conditions do you currently manage? *

Have you had extensive lab work or testing that hasn't led to satisfactory answers? *

Yes

Which best describes what you're seeking treatment for: (Select one) *

Single acute issue (sick visit, injury, routine check-up)

2-3 related symptoms lasting less than 6 months

Multiple unrelated symptoms lasting 6+ months

Complex multi-system symptoms (digestive + hormonal + neurological, etc.)

Autoimmune or suspected autoimmune conditions

Chronic fatigue, brain fog, or unexplained pain lasting 6+ months