Patient Forms
Fill out your intake packet before your appointment — on your phone, tablet, or computer. It takes about 15–20 minutes, and you can stop and come back.
Fill it out online
Complete the whole packet in your browser and sign with your finger or a typed signature. We turn it into a PDF and deliver it to the clinic securely.
- Works on any phone, tablet, or computer
- Saves your progress automatically on this device
- Sent over an encrypted connection
- You can download your own copy at the end
Print it instead
Prefer paper? Download the packet, print it, fill it in by hand, and bring it to your appointment.
Download printable packet (PDF)
The downloaded PDF also has fillable fields, so you can type into it on a computer before printing.
Need help?
Call the office at 636-333-2235 during business hours (Monday – Friday, 12:00 noon – 5:00 pm) and we will walk you through it, mail you a packet, or take the information over the phone.
What’s in the packet
Eight short sections. Have your medication list and recent lab results handy.
About you
Name, date of birth, and how you heard about us.
Contact & emergency
Address, phone, email, emergency contacts, and your physician.
Medical history
Current health, medications, allergies, and past surgeries.
Past & family history
Conditions you have had, and your family’s medical history.
Nutrition
Your weight history, goals, cravings, and past diets.
Lifestyle
Alcohol, tobacco, and activity level.
Consents
Financial policy, informed consent, and HIPAA acknowledgement.
Review & submit
Check everything over, sign, and send.
How your information is protected
- Your answers travel to us over an encrypted HTTPS connection.
- The packet is stored encrypted on a server we control — it is never emailed.
- Only clinic staff can retrieve it, through a password-protected area.
- While you are still filling it in, your draft stays in your own browser. You can clear it at any time from the form.
Read the full Privacy & HIPAA Notice.
Please don’t email us medical details
Ordinary email is not secure. Use this form or call 636-333-2235 instead.