Duquette Functional Medicine Logo

806 E Washington St., Bloomington, Illinois 61701

Patient Forms

Please do not fill out the intake form unless you have spoken to our team first!

Please have enough time, about 15 minutes, to fill out the intake form. If you must leave it and return at a later time, the site will ask for a passcode that you will receive in a separate message at that time.

Feel Free to contact us with any questions or technical issues.

Confidential Patient Intake Form