Forms
All of our forms are Adobe PDF documents. Once you download the necessary
forms to your computer, you may
type directly into them and save them on your computer as
you are working. To return any forms by email, please send
them as email attachments. You may also print the forms and
write on them if you prefer.
To access these forms you will need to have the free Adobe
Reader installed on your computer. Most computers already
have the Adobe Reader installed, but if you need to install
it please click this button:
To ensure the data you enter in the PDF documents displays and saves correctly, please do not use Preview on a Mac, or any PDF browser plug-ins. Download the PDF files to your computer and only open them with Adobe's PDF reader.
If you would prefer any of our forms be sent to you by mail or by e-mail, please contact our reception by phone at 650-595-5437 or by email at info@wholefamilywellness.org.
New patient forms
Thank you for your interest in becoming a patient at Whole Family Wellness. Please note that we are not accepting new patients. You may contact our reception at info@wholefamilywellness.org to be placed on our waiting list.
Before scheduling your first appointment, we ask that you take the time to review, fill out, and return the documents and forms as outlined below. A new patient appointment will only be scheduled after we receive your completed forms. Once we receive your completed forms, our reception will call you to schedule your appointment.
The information that you provide will greatly enhance and maximize the time you spend with your doctor or nutrition consultant on your first visit, so please fill out the questionnaires as accurately and thoroughly as possible. For consultations regarding specific health issues, we also ask that you send all previous medical records, including previous lab work and consultations with other healthcare specialists, to our office at least three days before your scheduled visit. This will ensure that your doctor can provide you with the best comprehensive care. Use the Authorization to Release Medical Information to Whole Family Wellness form to request medical records from your other healthcare providers.
You may return the forms in any of the following ways:
- E-mail (as email attachments) to info@wholefamilywellness.org
- Fax to 650-595-5438
- Regular mail to our office
address at:
Whole Family Wellness
1601 El Camino Real, Suite 101
Belmont, CA 94002
For new PEDIATRIC appointments, please complete the following:
- Review the Who We Are page of this website for our most recent provider information.
- Review the Whole Family Wellness Policies page of this website.
- Review the Notice of Privacy Practices document.
- Completely fill out the Pediatric New Patient Registration Form.
- Completely fill out the Pediatric New Patient Health Questionnaire.
- Completely fill out the Family History Form.
- Return the Pediatric New Patient Registration Form, the Pediatric New Patient Health Questionnaire, and the Family History Form to our office. Once we receive them, we will call you to schedule your appointment.
- Send all previous records and labs to us at least 3 days before your visit.
Other forms
Authorization To Release Medical Information to Whole Family Wellness - Use this form to request medical information be sent to Whole Family Wellness from another practitioner.
Authorization To Release Medical Information from Whole Family Wellness - Use this form to request medical information be sent from Whole Family Wellness to another practitioner. A record copy fee may apply as detailed in the Whole Family Wellness Policies document.