Name* Date of birth* MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Email* Phone* How you heard about us ?*Physician ReferralOnline Search EngineInstitute for Functional Medicine (IFM)Friends/FamilyFormer patient of Dr. PatelFormer patient of Cleveland Clinic IFM (not Dr. Patel)OtherPreferred Date MM slash DD slash YYYY Preferred TimeMorningAfternoonEveningMessage*Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.Please complete the following form to request an appointment. Please also note that availability will vary depending on your request. Your appointment will be confirmed by phone by a member of our staff. Thank you!PhoneThis field is for validation purposes and should be left unchanged.
