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Register with Functional Medicine SF

Welcome to the Functional Medicine SF registration page.

If you are already a registered patient with online access, you can log in here

Basic Contact Information

First Name * Middle Name (or initial) Last Name *

Date of Birth *

Social Security Number Nickname/Preferred Name Gender * Pronouns Race Ethnicity

Your Address

Address 1 * Address 2 City * State * Zip Code * Timezone

Contact Information

Mobile Phone Number Home Phone Number Work Phone Number Preferred Contact Number Email Address (Primary) * Secondary Email Address Home Fax Number

Contact Preferences

Non-medical automated notifications (such as informational or educational emails, news about the practice, promotions, or marketing emails) Email: SMS/Text:

Emergency Contact

First Name * Middle Name Last Name * Relationship to Patient Email Address Phone Number *

Insurance Information

Note: Our practice does not bill insurance, but this information makes it easier for us to refer you for other services (like labs or specialists) Plan Name Group Number Member ID Insurance Type

Medical Information

Please enter your basic medical information below. You may also add or edit this information after you've signed up.

Height (in INCHES) Weight (in POUNDS) Please describe the primary reason you want to be seen. Please be brief as you will have the opportunity to complete a more robust intake questionnaire once you're registered Please list your close relations with whom we can share medical information How Did You Hear About Dr. Daniel? (and other general comments)

Set Username and Password for Patient Portal

Please create a username and password that you will use to log into the Patient portal in the future.

Your username must be at least 4 characters long

Username *

Your password must be at least 8 characters long and include at least one number or special character.

Password * Confirm Password *

The patient portal gives you access to your medical records and lets you securely communicate with your doctors. When you sign up, you will receive an email with instructions for logging in.

Credit Card Information

Card Details

Card Number * Card Type * CVV Code *^{What is a CVV?} Expiration Date (mm/yy) * /

Credit Card Billing Address

First name on card * Last name on card * Billing Address * Zip/Postal Code * State/Province *

"I have read and accept the terms of the privacy policy below:" * "I have read and agree to the Client Informed Consent and Disclosure Statement below:"* "I have read and agree to the Office Policies below:"*

"I have read and agree to the NutrimentRx Integration Consent below:"*

Sign with mouse or finger:

Clear Signature