Thank you for your interest in working with Functional Medicine SF. We are honored that you've chosen us to partner with you on your journey back to health. We are excited to begin this journey with you. Functional Medicine SF and Medical Board of California Basic requirements The Medical Board of California requires physicians to see all new patients in person for the first appointment (subsequent appointments may take place via phone or video). At this time, Dr. Daniel & Dr. Cole accept patients, aged 18 and over If you are under 18, please contact our staff at firstname.lastname@example.org. Thank you! Please check the boxes below to indicate that you meet these basic requirements. Are you 18 years of age or older?*Yes, I am 18 years of age or older.No, I am not at least 18 years of age.Are you willing to travel to San Rafael, CA for the first appointment?*Yes ,I am willing to travel to San Rafael, CA for the first appointment.No, I am not willing to travel to San Rafael Ca.What Provider are you Interested in?*Stephanie Daniel D.OKatie Cole D.O.Brittany Forman, Functional NutritionistWhat services are you interested in at Functional Medicine SF*FUNCTIONAL MEDICINE CASE REVIEWINTUITIVE WOMEN’S WELLNESS (natural hormone balancing)DRUG-FREE FERTILITYMALE VITALITY PROGRAM (Hormone Program )FUNCTIONAL NUTRITION (health Coaching)LOW-DOSE NALTREXONE (LDN)HOLISTIC PSYCHIATRISTFUNCTIONAL MEDICINE RX MANAGEMENTOTHERWhat are your Functional Nutritional Needs and wantsPlease be as comprehensive as possibleDo you consider your health stable with no hospitalizations in the past year?*YesNoPlease explain details:*Do you have severe neurological conditions such as seizures, loss of consciousness, fainting or autonomic instability?*YesNoPlease explain details:*Do you have MS (multiple sclerosis), ALS (amyotrophic lateral sclerosis) or Parkinsons? **YesNoPlease explain history of illness*Do you suffer from severe anxiety, depression, rage,Bi-Polar, PTSD, OCD or any other Mental Health Issues?*YesNoPlease explain details*Will you want to follow-up Virtual (Phone or Video) or In person*Virtual (Phone / Video)In personHow did you hear about FMSF*Are you male of female*MaleFemaleYear of Birth*Have you been evaluated and or treated by another medical provider for this medical complaint?*Yes, I have been to other providers for this medical complaint.No, I have not been to other providers for this medical complaint.Current Medical Diagnosis and Complaints*Medical Diagnosis and ComplaintsDate Symptoms Started Are you currently taking any medications?*No, I do not take medicationYes, I take medicationOn a scale 1-10 How ready are you to: (10 being I will do anything, 1 being I'm not that motivated)Significantly modify your diet*10987654321Take nutritional supplements*10987654321Keep an updated health journal*10987654321Engage in relaxation techniques*10987654321Modify your lifestyle*10987654321Do regular Laboratory work to evaluate your progress*10987654321Which statement resonates more with you*It’s the doctor's job to heal me.It’s my job to heal myself with the guidance provided by FMSFFunctional Medicine SF Policy Acknowledgement Click here to read the PoliciesHave you read and understood the policies of FMSF*No, I have not read and or do not understand the policies of FMSFYes, I have read and understand the policies of FMSFI understand Functional Medicine SF does will not bill or submit to any insurance agency or Medi-care or Medi-Cal*We provide SupperBills for you to provide to your respected medical insurance carrier or system.Yes, I understand I must provide payment at time of service.No, I want to submit the bill to my insurance carrierNo, I want to use Medicare or Med-iCalName* First Last Email* Phone****IMPORTANT NOTE: This will take you to a short video that completes the application. Please add the domain “@functionalmedicinesf.com" to your contacts/safe senders list in your email client or the confirmation email will be sent to your spam folder*** This iframe contains the logic required to handle AJAX powered Gravity Forms.