Consent Forms
Health Questionnaire 

Directions:

 

  1. Please click to download the document and complete in its entirety.

  2. Return document to FMG using ONE of the following methods:

 

  • Mail to: Functional Medicine Georgia

 13680 Hwy 9 N, Bldg. F - Suite    400, Milton, GA   30004 

 

  • Fax to: 678-242-0406

Attention: Office Manager

Becoming an FMG Patient:

 

Becoming a patient at Functional Medicine Georgia requires a serious, commitment of your time, focus, and energy as well as a financial investment in your health. FMG does not accept insurance. The 'Health Questionnaire and Consent Forms must be completed and returned to the office before your first appointment will be booked. The questionnaire and consent forms will be reviewed by Doctor Doniparthi, prior to your visit. 

Medicare Private Contract

Attention Medicare Patients:

 

All Medicare patients are legally required to sign a private contract in order to be seen at FMG, per the Center of Medical Services (CMS).

 

Notice of Privacy Practices Acknowledgement

Follow Dr. Doniparthi :

Tel : 678-242-0219

Fax : 678-242-0406