NPI Become a patient: What Service are you Interested in?*Functional Medicine PatientIV Infusion & Injection PatientWelcome 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. Name* First Last Email* Phone*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.What are your Needs and Wants? What are you looking to resolve?*Please be as comprehensive as possibleWhat are your current symptoms and concerns?*I understand the New Patient Welcome Consult does not establish a Doctor – Patient relationship.*YesNoI understand the Consult Fee is $150 for a 15 minutes. This fee is charged at time of scheduling the consult.*YesNoDo you suffer from severe anxiety, depression, rage,Bi-Polar, PTSD, OCD or any other Mental Health Issues?*YesNoPlease explain details*Have you had any major diagnoses?*How did you hear about FMSF*Are you male or female*MaleFemaleAge*Please enter a number from 0 to 99.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.How many doctors have you been to for this medical concern?0-23-67-10On 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 PoliciesScheduling 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*Yes I understandContinuing 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.*Yes I understandYou 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.*Yes I understandHave 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 have read and understand the new patient pricing, FMSF membership fee and billing model?*Membership Fee starts the day of your New Patient Appointment. Yes, I understand FMSF new patient pricing & Membership FeeNo, I do not understandI understand Functional Medicine SF 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-iCalHow did you hear about us?*What infusions are you interested in?* Ketamine – For qualified patients, psychiatrist referral 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 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*** This iframe contains the logic required to handle Ajax powered Gravity Forms.