New Patient Questionnaire

Midwest Functional Medicine | Dr Robert Hermann

Please correct the errors described below.

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Patient Information

Medical History

Please click submit when finished. We will contact you after we review, usually within one or two business days. Not all patients are accepted. We only accept patients we are sure we can help. There will be a more extensive consultation after records are received. There is no charge for a consultation. There is only a fee if you decide to accept treatment and we decide to accept you. Please put best contact time for phone calls.

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