Cash Only Agreement Application

Please complete the following forms. A PDF copy of completed forms will be emailed to you and SFM, (password protected). Upon review of the forms, SFM will contact you.

Each form redirects to the next form when finished, but if you don’t complete all the forms at once, you may return to this page to start the next form.

Virtual private networks (VPNs), browser pop-up blockers and anti-virus software my prevent the online forms from submitting. It is highly recommended to turn off VPNs prior to starting the forms.

Completion of Application does not establish a provider/patient relationship with SFM.

  1. Applicant 3 SFM Disclosures
  2. Applicant 3 Health History
  3. Applicant 3 24-Hour Diet Recall
  4. Applicant 3 IFM Questionnaires