Bloom Functional Medicine
Shopping Cart
Your Cart is Empty
Quantity:
Subtotal
Taxes
Shipping
Total
Please complete the new patient form (see below) and medical record release form. Return both to Bloom Functional Medicine along with a copy of your insurance card and ALL relevant labs/testing that has been done. Once received, the doctor will review you will be sent an invite to Charm Portal to schedule new patient visit.
Please note, this review can take 1-2 weeks, so please be patient. The best way to have the process go faster is to be careful and complete in completing the forms and return all forms completely filled out.
Checklist for new patients:
____New Patient Form (see below)
____Medical Record Release Form (Be sure to complete one for EACH provider we are sending it to. Initial and sign in all areas noted)
____Insurance card (front and back)
____All relevant medical records
Return via fax, mail or email. Please do NOT send screenshot of forms.
The forms need to be easy to read by staff and providers and each form in its own complete PDF. If you do not have a scanner, you can fill it out on computer in Adobe (or similar). You can also print, complete forms, then mail, fax or drop off at clinic.
Mail: 15 82nd Drive, Suite 100, Gladstone, Oregon 97027
Email: [email protected]
Fax: (503) 656-8080
Text: (503) 831-9231
Please complete the new patient form (see below) and medical record release form. Return both to Bloom Functional Medicine along with a copy of your insurance card and ALL relevant labs/testing that has been done. Once received, the doctor will review you will be sent an invite to Charm Portal to schedule new patient visit.
Please note, this review can take 1-2 weeks, so please be patient. The best way to have the process go faster is to be careful and complete in completing the forms and return all forms completely filled out.
Checklist for new patients:
____New Patient Form (see below)
____Medical Record Release Form (Be sure to complete one for EACH provider we are sending it to. Initial and sign in all areas noted)
____Insurance card (front and back)
____All relevant medical records
Return via fax, mail or email. Please do NOT send screenshot of forms.
The forms need to be easy to read by staff and providers and each form in its own complete PDF. If you do not have a scanner, you can fill it out on computer in Adobe (or similar). You can also print, complete forms, then mail, fax or drop off at clinic.
Mail: 15 82nd Drive, Suite 100, Gladstone, Oregon 97027
Email: [email protected]
Fax: (503) 656-8080
Text: (503) 831-9231
PCP/Dr. Meigs New Patient Intake Form
Functional Medicine Intake Form
Please complete this form and send to all providers who have seen you for the condition we are consulting you for. It often takes 30 days for medical records to be sent, so please send ASAP