Quick & E-Z Patient Forms
Welcome to our (4) EZ Patient Intake Registration Forms. Please only choose one which applies to your needs. The information you fill in will be sent directly to our office, speeding up your initial office visit. I have also have added a fourth Institue Functional Medicine Detailed Online Intake Form for those seeking assistance and treatment with chronic degenerative conditions. Also, do share these links with those who need immediate care.
Again, I welcome you to our office. God Bless & Great Regards:
Dr. Alex Jimenez 👊🏽
- Below you will find 4 New Patient Registrations.
Choose Only One
- #1 Online Version
- #2 Printable Version
- #3 Printable Accident & Injury Version
- NEW – Functional Medicine Assessment Form Learn More
- #4 Institute of Functional Medicine Assessment (IFM)*
✔️ Online Registration – #1
Our Quick n’ Easy Secured Online ☁️ Access Registration Form is available in order to expedite the initial new patient intake process.
✔️ Printable Registration – #2
Below you can generate an optional printable version of your Patient Intake form if you prefer not to fill out your form via the web or iPad.
✔️Printable Registration: Personal Injuries #3
Note: Injured due to a Personal Injury 🚑 ? Use this optional printable version. Most injury cases have unique circumstances that require additional information. This form allows for important and specific details to be documented properly for your providers.
✔️ Online Functional Medicine Registration #4
Note: Functional Medicine* and it’s thorough approach to treatment requires a detailed history and assessment. Our providers will assess your personal clinical data with an additional functional medicine approach. Our goal will be to find the true causes of your chronic conditions and to treat you with an in-depth holistic approach. Your information will securely be sent to a functional medicine specialist that will discuss your issues in detail. Our format and clinical questionnaire follow the most stringent Institute of Functional Medicine Mandates. Learn More
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