Apply to Work With Us "❋" indicates required fields Step 1 of 16 6% Patient Name❋ First Last Please make sure the application contains the name of the patient and not another family memberPhone❋ >>>IMPORTANT<<You MUST use a UNIQUE email address for the individual person applying for membership. Gmail offers a free account with parental monitoring for any child. If an email is used that is already attached to an existing patient, their administrative record will be overwritten.For non-minors, you may also follow these instructions to set up forwarding to another email address: Gmail forwarding❋ *Patient* Email Confirm *Patient* Email For non-minors, you may also follow these instructions to set up forwarding to another email address: Gmail forwarding Before you proceed, you may wish to review our Financial Policy in greater detail. Please answer ALL of the following questions to the best of your ability:I understand that RIFM is a functional medicine practice and not a 'concierge' medical practice* (if your application is approved, you'll received a detailed membership contract to review)❋ Yes No *More details can be found at: Does RIFM offer concierge medicine? I've read the FAQ to address my questions about RIFM❋ Yes No I don't have questions The FAQ page includes costs, what's covered in the membership, and numerous other questions I will commit to meeting with my health coach during the sessions provided with my membership❋ Yes No Do you have a standard insurance plan?❋ Yes (e.g., Medicare, etc) No, I wish pay cash (and I do not have other insurance) No, I have a health sharing plan (e.g., Samaritan Ministries, MediShare, etc) What is your main health complaint?❋ How often does it bother you?❋ Everyday Once per week 2 to 3 times per week Once per month How long has it been going on?❋ 1-6 months 1-3 years Over 3 years What (or who) would prevent you from completing a functional medicine program or plan (e.g., lifestyle changes, supplement supports)? Children Spouse/Partner Money Self Job Fear Time None of these What have you tried so far that has or has not worked?❋ What is your current diet like? Please be specific: list breakfast, lunch, dinner and snacks, as well as the times you eat.❋ Are you taking any supplements or medications? Please list what you take and what it's for.❋Note: It may help to leave spaces in certain medication names so they are able to be submitted (e.g., Va lium) What would you like your health to be in 3 months from now? How about 6 months from now?❋ What obstacles, challenges, and struggles do you face regarding diet/lifestyle?❋ If we were to work together what would you expect to achieve from working with us?❋ What are 5 things you LOVE about your life?❋CommentsThis field is for validation purposes and should be left unchanged. Δ
