Advanced Functional Medicine

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Functional Primary Care

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Application for Advanced Functional Medicine

Veronica Porterfield joins RIFM in June 2025. She is accepting new in-patient members for AFM.

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Step 1 of 12

This application will require 15–30 minutes to complete. Please answer questions thoroughly.

Applicant Clarification

Who is this application for?

For Me

For a Dependent

Your Contact Information

My Name*

First Last

My Email*

*My* Email Confirm *My* Email

Applicant Phone*

Dependent Information

Dependent Name*

First Last

Dependent Age

How old is your dependent?

Dependent Email Option

We need a unique email for your dependent, but if you don’t have a second email, we can help you to generate an alias that will still send emails to your email.

I’ll provide a second email

Please generate a system alias

Dependent Email*

*Dependent* Email Confirm *Dependent* Email

Previous Experience

Family Connections*

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.

Member Connection*

First Last

Previous Experience*

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

Aaron Hartman

Christian Jenski

Jodi Caddell

Veronica Porterfield

No previous experience

Health Insurance

Insurance Check*

Do you have a standard health insurance plan?

Yes

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

Payment Intention*

How would you intend to pay for office visits?

I will pay for office visits with cash

I am part of a group sharing plan

Insurance Provider*

Please select your insurance provider:

Aetna

Anthem (Blue Cross / Blue Shield)

Cigna

Humana

Medicare

Multiplan

United Healthcare

Other

Other Insurance*

Please provide:

Insurance Plan*

Which type of plan do you have?

HMO

PPO

EPO

Other

RIFM does work with the insurance provider you have provided for most standard HMO & PPO plans. However, because you have listed “other,” for your plan, we cannot pre-qualify you.

Please proceed with the rest of the application, but we will need to clarify your insurance.

Unfortunately, RIFM does not participate in the insurance network you’ve provided. Membership with RIFM is still possible without health insurance, but would require paying for visits and any labwork out-of-pocket.

Payment Follow-Up

Would you be able to pay for office visits with cash (i.e. out-of-pocket)?

Yes, I will pay for office visits with cash

No, I cannot pay for visits without insurance

Parent Note

Please fill out the following section on behalf of the dependent. Any references to “you” or “your” should be considered your dependent.

Overall Health

On a scale of 1–5, how happy are you with your present health?*

TerribleNot so greatNeutralPretty goodExcellent

Health Concerns

Primary Concern

What is your main health concern?

Frequency of Concern*

How often does it bother you?

Every day

2 – 3 times per week

Once per week

Once per month

Duration of Concern*

How long has it been going on?

1–6 months

1–3 years

Over 3 years

Progress / Setbacks

Progress/Setbacks*

What have you tried so far that has or has not worked?

Current Diet

Please describe your current diet.

Diet Frequency*

How often do you eat per day?

Less than twice per day

2–3 times per day

3 meals per day (no snacks)

3 meals plus occasional snacks

3 meals plus frequent snacking

Frequent, intentional grazing

Frequent, unintentional grazing

Typical Breakfast*

Typical Lunch*

Typical Dinner*

Typical Snacks*

Lifestyle Challenges*

What obstacles, challenges, and struggles do you face regarding diet/lifestyle?

Medications & Supplements

Are you currently taking any medications or supplements? Please list anything you take and it’s intended purpose.

Medications and Supplements

What You’re Taking

Intended Purpose

Health Goals

Health Goals*

What would you like your health to be 6 months from now?

Expected Outcomes

Expected Outcomes*

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

Potential Barriers

Obstacle List*

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

Barrier Clarification: Children

Please elaborate: How would your children create a barrier to completing a functional medicine program?

Barrier Clarification: Partner

Please elaborate: How would your spouse or partner create a barrier to completing a functional medicine program?

Barrier Clarification: Money

Please elaborate: How would money create a barrier to completing a functional medicine program?

Barrier Clarification: Self

Please elaborate: How would you create a barrier to completing a functional medicine program?

Barrier Clarification: Job

Please elaborate: How would your job create a barrier to completing a functional medicine program?

Barrier Clarification: Fear

Please elaborate: How would fear create a barrier to completing a functional medicine program?

Barrier Clarification: Time

Please elaborate: How would time create a barrier to completing a functional medicine program?

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Number of Loves

Please enter a number from 5 to 5.

5 Loves*

What are 5 things you LOVE about your life?

Apply to Work With Us

Application for Advanced Functional Medicine

Your Contact Information

Dependent Information

Previous Experience

Health Insurance

Parent Note

Overall Health

Health Concerns

Progress / Setbacks

Current Diet

Medications & Supplements

Health Goals

Expected Outcomes

Potential Barriers

Our Team

Get Directions

Contact Us

Nutrition & Supplements

Nutrition

Understanding Supplements

Compare Food Plans

Ask For Help

Patient Membership

Explore Membership

Member Resources

Log-In/Register Membership Details

Log-In/Register Member Resources

Member Patient Portal Patient Portal (Elation)

Ask Questions

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