NPI – Functional Medicine SF

Become a patient:

What Service are you Interested in?*
Welcome to Functional Medicine SF
Thank you for your interest in working with Functional Medicine SF.
At this time, Functional Medicine SF is accepting patients, aged 18 and over
If you or the patient are under 18, please contact our staff at Click Here. Thank you!
Please check the boxes below to indicate that you meet these basic requirements.
Prospective PT Form

Functional Medicine SF offers paid 15 minute consults with Dr. Daniel to see if you might be a good fit for Functional Medicine SF.
To schedule a 15 minute consult please complete the form below and then register in our online patient portal.

This form will lead you to your online patient portal. Select Prospective Patient on the registration.
A member of our team will contact you within 48 Hrs to setup
Name*
First Last
Email*
Phone*
Are you 18 years of age or older?*
What are your Functional Nutritional Needs and Wants?*
Please be as comprehensive as possible
What are your current symptoms and concerns?*
Have you had any major diagnoses?*
Were there specific treatment strategies (medications, supplements, diets, therapy, exercise) that improved your condition(s)? If so, please describe:*
What are your health goals?*
I understand a Prospective Patient Consult does not establish a Doctor – Patient relationship.*
I understand the Consult Fee is $150 for a 15 minutes. This fee is charged at time of scheduling the consult.*
Do you suffer from severe anxiety, depression, rage,Bi-Polar, PTSD, OCD or any other Mental Health Issues?*
Please explain details*
How did you hear about FMSF*
Are you male of female*
Age*
Please enter a number from 0 to 99.
Have you been evaluated and or treated by another medical provider for this medical complaint?*
How many doctors have you been to for this medical concern?
On 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*
Take nutritional supplements*
Keep an updated health journal*
Engage in relaxation techniques*
Modify your lifestyle*
Do regular Laboratory work to evaluate your progress*
Which statement resonates more with you*
Functional Medicine SF Policy Acknowledgement
Click here to read the Policies
Scheduling an appointment; Initial appointments are made via the patient portal in MD-HQ Once you have registered, send up a secure message in our online medical record system (MD-HQ: Patient Portal) that you are ready to schedule your New Patient appointment. You are required to complete your intake forms prior to scheduling. Please upload any prior lab results, supplements and medications you may be taking to your "Patient Portal" in MD-HQ. Established Patient: request an appointment time via the Patient Portal*
Continuing Care ; To ensure that each patient understands their commitment and expectations and to increase our quality of care we would like to point out the following: Follow-up consultations must take place per patient recommendations. Continual failure to comply with protocol recommendation timeline will result in dismissal from functional medicine SF.*
You are REQUIRED to have a separate primary care doctor; VERY IMPORTANT Dr. Stephanie Daniel offers functional medicine consultation only. We do not offer after-hours or urgent care - you must have a primary care doctor for this purpose. This also means she is unable to respond to urgent requests of any sort, including messages and phone calls.*
Have you read and understood the policies of FMSF*
I have read and understand the new patient pricing, FMSF membership fee and billing model?*
Membership Fee starts 6 months from your New Patient Apt.
I 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.
How did you hear about us?*
What infusions are you interested in?*
- Ozone
- UVB
- NAD
- Ketamine – For qualified patients, psychiatrist referral
- Custom
Functional Medicine SF does not prescribe Ketamine,
Your prescribing provider needs to send us a copy of their prescription of Ketamine for you along will your treatment plan.
Your provider and our providers will connect and set-up your treatment here at Functional Medicine SF.
Name of your Prescribing Doctor*
Email of your Prescribing Doctor*
Phone Number of your Prescribing Doctor*
Don't have a Provider willing to prescribe Ketamine?*
- Yes
- No
Providers Functional Medicine SF Trust and work with:
Cara T. Hoepner, MS,  RN,  CS,  PMHNP-BC
Four  Embarcadero  Center
Suite  1400   SF
tel:   415.967.3921      |      fax:   415.426.2002
BAY • AREA • PSYCHIATRIC
Custom*
Clicking Submit will take you to Part 2 of the registration process, to finalize your registration.
***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***

Save and Continue Later

Become a patient:

Welcome to Functional Medicine SF

Prospective PT Form

Functional Medicine SF Policy Acknowledgement