Contact UsReach out to discuss how we can support your health and wellness journey Have Questions? Let's Talk!If you have questions about our services, programs, or anything else, feel free to reach out. We're here to help!*We typically respond within 24-48 hours* Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. Scheduling Intake Form (New and Return Patients) - Step 1 of 4Name *FirstLastPhone Number *Email *Next Are you a new or existing patient? *New PatientEstablished/Return PatientInquiry OnlyNext Did you already book your appointment? *YesNoNext Gender *FemaleMaleOtherDate of Birth *Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWhat service(s) are you interested in? *Accelerated Resolution TherapyBloodwork/Lab Testing (Prenatal labs, genetic testing, infertility work-upy Hormone level, nutritional deficiencies, cholesterol, pregnancy testing, etc.)Infertility/Conception/Family PlanningGut Health/Microbiome/ImmunityWomen's Health Services (prenatal/postpartum-only care, IUD, birth control, pap smear)IV Therapy/Vitamin InjectionsWeight Loss SupportMental Health Services (Sleep, Stress, perinatal mood disorders)Menstrual/Sexual HealthReason for Visit * If Est/Follow-up to Do you prefer In-person or telehealth visit? *In-PersonTelehealth/VirtualNo PreferenceCOMMENTS/OTHERIf no other comments, type N/ARequest Promotional $99 Consultation?YesWhat best describes your financial situation? *I have insurance and I only want services my insurance will cover?I don't have insurance and can pay for services out-of-pocketI have insurance and can also pay for services not covered by insuranceDo you have health insurance? *YesNoSome services may be covered by insuranceInsuranceInsurance Name *Claim Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMember ID#/Group ID# *Upload Front and Back of Insurance Card Click or drag a file to this area to upload. Insurance Guarantor? *SelfOtherGuarantor's Name *FirstLastGuarantor's Date of Birth *Guarantor's Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePast Medical History (PMH)Chronic Illnesses *Surgeries *Allergies *Established Patient Past Medical HistoryAny changes since your last visit?New surgeries/procedures, injuries/illnesses, family history, medication, etc? *Type: N/A or None if no changesReview of Systems (ROS)Patients are often asked to check any symptoms they currently have or have had in the last 6-12 months. Respiratory *Shortness of BreathCoughWheezingChest TightnessHemoptysis (coughing up blood)N/ACardiovascular *Chest PainPalpitationsShortness of breathLeg swelling or edemaHistory of fainting or syncopeN/ANeurological *HeadachesDizzinessSeizuresNumbness or tinglingMemory loss or confusionN/AEndocrine *Excessive thirstExcessive hungerHeat or cold intoleranceWeight gain or lossFatigueN/AGenitourinary *Painful urinationFrequent urinationBlood in urineSexual dysfunctionMenstrual irregularities (for females)N/AMusculoskeletal *Joint painMuscle painBack painSwelling in jointsLimited range of motionN/ADermatological *RashesItchingDry or oily skinAcne or skin eruptionsMoles with changes in size, shape, or colorN/APsychiatric *DepressionAnxietyMood swingsHallucinations or delusionsSleep disturbancesSuicidal thoughtsHomicidal thoughtsSelf-Harm thoughtsN/ASubstance Use (Last 6-12 months) *Drink AlcoholUse tobacco/nicotine productsUse recreational/street drugsUse/Drink caffeine productsNoneOther Symptoms/Conditions Not ListedConsent and AcknowledgmentConsent to Proceed *I hereby give my consent to undergo the health screening as described above. I understand the procedures involved and acknowledge that I have had the opportunity to ask questions regarding the purpose of the health screening.Privacy Acknowledgment *I acknowledge that I have read and understand the privacy policy concerning the handling of my personal and health information and agree to the use of my data in accordance with this policy.Telehealth Consent *I understand that all the laws that are protecting my privacy of medical history or information are also applied to telehealth practices. I understand that I can withdraw the consent at any time and that will not affect any of my future treatment procedures. I understand that I can be charged the additional fees that my insurance does not cover. I accept that I authorize health care professionals and use Telehealth for my treatment and diagnosis.Confirm Your Appointment & Deposit *By checking this box, I confirm that my appointment has been booked and my deposit has been paid over the phone with an authorized Journey2Wellness staff member. I understand that no further payment is required at this time.Signature * Clear Signature Consultation FeeNew Patient Consultation Fee *Consult Fee - $175.00Enter Discount code: VJM5RN4A Apply Discount code brings consult fee to $99Total$0.00Check This Box If You Are Completing on Behalf of the PatientPatient RepresentativeDepositNon-refundable deposit will be applied to your appointment and/or any outstanding account fees. Deposit Date *Est/Follow-up Security Deposit *Price: $50.00Non-refundable deposit will be applied to your appointment and/or any outstanding account fees. Security Deposit (New PT w/ Insurance) *Price: $75.00Non-refundable deposit will be applied to your appointment and/or any outstanding account fees. Square *CardName on CardSignature Consent *By typing my name below, I understand and agree to the terms of this agreement and authorize my card charged for the deposit amount and that this form of electronic signature has the same legal force and effect as a manual signature.TYPED NAME as ELECTRONIC SIGNATURE *Signature Consent (Proxy) *I give verbal consent for a Journey2Wellness Representative to type my name below. I understand and agree to the terms of this agreement and authorize my card charged for the deposit amount and that this form of electronic signature has the sameBy Proxy TYPED NAME as ELECTRONIC SIGNATURE *Submit More Ways Phone :402-884-9059 Fax :833-875-0053 Email: info@j2wllc.org Address: 401 E Gold Coast Rd #340, Papillion, NE 68046 Follow Me On Social Media
