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Functional Health Program Fit Form

At Benton Integrative Medicine, we are committed to doing all we can to support you and the following questions will help us learn more about the best fit for your needs. Once completed and reviewed you will be contacted to schedule a consult or pursue other next steps. We look forward to talking further to learn about your goals and expectations moving forward!

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Please fill out the form below to get started. We will contact you to set up an appointment to get started. 

What lab testing have you completed over the last two years? Check all that apply.
To what extent are you financially able to do what’s necessary to reclaim your health (i.e., making diet and lifestyle modifications, purchasing targeted supplements and necessary functional health testing to explore your case further)

Thank you for filling out the form! We will be in touch soon.

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