Apply to Work With Us Functional Primary Care Advanced Functional Medicine Learn more about our membership models. Application for Functional Primary Care Please take your time and answer all questions. We will review your application and respond within 1-2 business days. "❋" indicates required fields Step 1 of 5 - Patient Info 0% Note: Current RIFM Members do not need to apply for Functional Primary Care. It is included in your membership. Call our office to schedule a primary care appointment. Applicant Clarification❋ Who is this application for? For Me For a Dependent Note: Please fill out the rest of the application as if you were the dependent. Any references to “you” or “your” should be considered your dependent. Patient Name❋ First Last Phone❋ IMPORTANT!You must use a unique email address for the individual person applying for membership. If an email is used that is already attached to an existing patient, their administrative record will be overwritten. Gmail offers a free account with parental monitoring for any child. For non-minors, you may also follow these instructions to set up forwarding to another email address: Gmail forwarding Email❋ *Patient* Email Confirm *Patient* Email Insurance❋ Do you have a standard insurance plan? Yes No Insurance ProviderPlease include your insurance provider: Payment Intention❋ How do you intend to pay for office visits? I will pay for office visits with cash I am part of a group sharing plan Group SharingPlease include your group sharing plan: Three Month Goals❋What would you like your health to be 3 months from now? Six Month Goals❋What would you like your health to be 6 months from now? Barriers❋ Are there any barriers that might prevent you from completing a functional medicine program or plan (e.g. lifestyle changes or supplement supports)? Children Spouse/Partner Money Self Job Fear Time None of these Expectations❋If we were to work together what would you expect to achieve from working with us? Previous Experience❋ Have you previously worked with Jodi Caddell? Yes No Five Loves❋What are 5 things you LOVE about your life? Family Connections❋ Are any of your family members active members with Richmond Integrative & Functional Medicine? Yes No Name Please provide their name (the primary member if there are more than one) First Last Family EmailPlease provide their email (it is safe to include an email here that is already in our system). CommentsThis field is for validation purposes and should be left unchanged. Δ
