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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. 

Checklist for new patients:

____New Patient Form (see below)

____Medical Record Release Form

____Insurance card (front and back)

____All relevant medical records

Return via fax, mail or email. 

Mail:  15 82nd Drive, Suite 100, Gladstone, Oregon 97027

Email:  [email protected]

Fax: (503) 656-8080

Male New Patient Form

Female New Patient Form

Medical Record Release 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