Become a New Patient | Streamline Your Onboarding Process

Let's start with your details

Please provide your details below so we can contact you about your patient onboarding.

Legal name

Date of birth

Phone number

Are you a Missouri resident?

Yes No

Thank you for your interest in 417 Integrative Medicine. Because we can only treat Missouri residents or patients who can visit our Springfield clinic, we are not able to move forward with a new patient intake at this time. If your situation changes, you are welcome to come back and complete this form. You can also change your answers above at any time.

Health Conditions Checklist

Please answer Yes or No for each condition below. This helps your provider understand your full health history before your first visit.

Other conditions not listed above (optional)

Your top reasons

What are your top 4 reasons or complaints for seeking care at 417 Integrative Medicine?

Care history

Have you seen any conventional or functional/integrative medical providers for your symptoms, diseases, or concerns?

Yes No

Current regimen

What medications, supplements, or treatments are you currently utilizing?

If none, write None.

Willingness scales

For each question, choose the option that best describes you.

Treatment interests

Are there specific types of treatments or therapies you are interested in?

If none, write None.

How we work

We are an integrative and functional medicine clinic, and most of our services are fee-for-service (cash pay). Membership options are available, but memberships are not required. Please view these on the Membership tab.

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New Patient Intake

Let's start with your details

Health Conditions Checklist

Your top reasons

Care history

Current regimen

Willingness scales

Treatment interests

How we work

How you found us

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Let's start with your details

Health Conditions Checklist

Your top reasons

Care history

Current regimen

Willingness scales

Treatment interests

How we work

How you found us

Submit

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Quick Links

Contact