Prospective Pt form | HometownFamilyHealth

Help us understand what type of care you are looking for so we can guide you to the right next step. Please note: This interest form does not schedule an appointment. Once submitted, our team will review your request and contact you regarding scheduling, next steps, or waitlist options.

Name

Date of Birth

Current Primary Care Provider (if any)

Preferred HFH provider (if any)

Most recent physical / wellness / chronic care visit

Best phone number

Do you have health insurance coverage?

Yes

If yes, what type?

Type of care you are interested in

Establish with an HFH provider for primary care

HIH initial visit / integrative consultation

Functional testing (GI MAP, DUTCH, toxin testing, etc.)

Second opinion on a current condition

PRP

Liquivida / massage / other therapies

Peptide-supported weight loss

Other service or care of interest

What are you hoping we can help you with?

If seeking functional testing or a second opinion, briefly describe what you are looking for.

Current conditions

Current medications

IMPORTANT: Prospective patients cannot be seen before their scheduled HFH Establish Care visit or HIH Initial Visit.