Patient Appointment Form Please fill out this form, and you will be able to schedule your complimentary discovery call once submitted. Name* First Last Date of Birth* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* What are your top 3 challenges that you would like us to help you overcome?*Why are these health goals important to you?*What is stopping you from accomplishing these goals?*If you were to wake up tomorrow without these challenges, how would your life be different?*What are the top factors that motivate you to invest in these problems?*Do you have a strong support system to help you in this journey? (e.g., family, friends, significant other)*On a scale of 1-10, how coachable do you feel you are?*Not coachableSomewhat coachableNeutralCoachableVery coachableWhat are the characteristics you value in a doctor-patient partnership?*How do you best learn? (e.g., reading materials, videos, podcasts)*Who else have you worked with?* Functional Medicine Practitioner Integrative Medicine Physician Medical or Osteopathic Doctor Naturopathic Doctor Traditional Chinese Medicine Practitioner Nutritionist Personal Trainer Chiropractor Personal Development Coach Other If other, please describe* What functional lab testing have you had done?* Functional Stool Testing Organic Acids Testing Genetic or Genomic Testing Hormone Testing Heavy Metal Testing None Other If other, please describe* Considering your past treatments, what would you like to improve or do differently moving forward?*Are you willing to do what is necessary to improve your health (dietary changes, lab testing and/or lifestyle modifications)?*Are you willing to invest in a personalized health plan that would address your health and wellness goals and have long lasting effects?*Select OneYesNoWould you be interested in joining a Facebook group hosted by our practice? The purpose of the group is to share health and wellness information and provide you with an opportunity to ask general questions about healthy lifestyle and nutrition.*Select OneYesNoIf yes, what topics would you like us to discuss?*How did you hear about us?*IFM websiteGoogle searchI was referred by my doctor or practitionerPodcastEventSelect OneFacebookInstagramReferred by a friendOtherPlease describe* What are your top three health and wellness questions you would like us to address in our future content?*Email Consent* Add me to Dr. Bojana's health letter.I want to receive the latest health news, practical wellness tips and recipes from Dr. Bojana. I understand that my email will not be shared with anyone, and that I can opt out anytime.Important! After pressing the Submit button, please wait to be redirected to the scheduler in order to schedule your appointment. In may take a few moments.