Wait List Application Question Title * 1. Email Address: OK NOTE: We want to emphasize that we are a Primary Care facility first and because of this, patients must be with us for a minimum of 6 months before having access to our Functional Medicine services. Thank you for your understanding. OK Question Title * 2. First Name OK Question Title * 3. Last Name OK Question Title * 4. Addresss OK Question Title * 5. City OK Question Title * 6. State OK Question Title * 7. Zip Code OK Question Title * 8. Telephone OK Question Title * 9. Insurance Name OK Question Title * 10. Who are you signing up for? Myself Spouse Children All of the Above OK Question Title * 11. Provider Preference Dr. Kate Atkinson, MD, PC Charles Milch, MHP, MBA, PA-C Katelyn Dutkiewicz, PA-C Miranda Tsoumas, PA-C Jenna Gigliotti, PA-C No Preference OK Question Title * 12. How did you hear about us? OK Question Title * 13. How were you referred to us? OK DONE