Functional Medicine Intake Forms

Your intake form is one of the most important aspects of your care and program. Please take your time carefully filling out the form and follow the instructions below carefully:

Both the Intake Form and Consent Form must be filled out and saved in Adobe or printed and filled out manually. DO NOT fill it out in your browser.

Take your time telling your story. The more we know, the better we can help. If you are not sure how to answer, leave a question mark next to the question.

Please fill this paperwork out completely. Do not leave any section blank. This paperwork is part of your exam. If the paperwork is not completely filled out at the time of your appointment you will have to reschedule.

You may send the filled out form to info@drcrifase.com once completed or bring it to your consultation.

Please click on the blue buttons below to download the forms.

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