This intake form is HIPAA-compliant and your data is fully secure. Any private information shared with us is kept strictly confidential and is never shared with anyone.
These shorter visits are exploratory consultations to speak directly with a Functional Medicine Practitioner and ask questions. You will walk away from the consultation with a better understanding of the specialty, the different therapeutic strategies it's focused on, and how they may help with a variety of chronic and autoimmune diseases, and other chronic inflammatory conditions. Please note that due to the limited time, the doctor may not be able to review medical records, labs, etc., unless you book the 60-minute consultation.
Attention: Our in-house Functional Medicine Specialist will review your medical records during the consultation, not before or after. If you have a long medical history, this can take up extra time for which we will invoice you separately.
Want to skip the exploratory consultations and go all in? Great! To start your Functional Medicine journey, a 90-minute consultation is required. Go back to the previous question and choose "I'm ready to become an established patient and schedule a 90-minute visit" instead.
Please enter your Blood Pressure in the format: larger number / smaller number: *
Please upload any new relevant medical records, images, videos, lab results, or pathology reports that you believe Dr. Haider may require. You can also do this later via the doctor's encrypted and secure chat.We respect your privacy. All uploads are kept on our encrypted server with strict safeguards against hacking and multiple layers of security.
Please upload any relevant medical records, images, videos, lab results, or pathology reports that you believe Dr. Haider may require. You can also do this later via the doctor's encrypted and secure chat.We respect your privacy. All uploads are kept on our encrypted server with strict safeguards against hacking and multiple layers of security.
You can share the documents via our secure patient portal or please email us the required documents at firstname.lastname@example.org.
Clicking the Pay Now button below will open a separate browser tab where you will be asked to submit your payment information. After submitting your payment, please return to this tab to complete this form. We will not receive your submission until you have completed this form.
Thank you for filling out the intake forms. After clicking CONTINUE, your info will be submitted.
Please check your inbox for the email confirmation and next steps.
Thank you for your payment and scheduling an appointment. Please make sure to click the 'SUBMIT AND CONTINUE' button below, otherwise, we will lose your information.
In the next pages, we'll ask some questions related to your health. We'll also need your identification to establish a doctor-patient relationship. It will be just a few minutes, you're almost done!