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. - Step 1 of 4Name *FirstLastPhone Number *Email *NextSave and Resume LaterAre you a new or existing patient? *New Patient (Insurance)New Patient (membership/direct care)Established/Return Patient (Insurance)Established/Return Patient (membership/direct care)Inquiry Only (Potential Patient)Inquiry Only (Not patient care related)NextSave and Resume LaterInquiry Only - NOT Patient Care Related *Send question(s) to email: info@j2wllc.orgNextSave and Resume LaterCheck This Box If You Are Completing on Behalf of the PatientPatient RepresentativeGender *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 Therapy (ART)Mental Health Services (Addiction, Anxiety, ADHD, Autism, Bipolar, Depression, Perinatal Mood Disorders, PTSD, Sleep, Stress, etc)Infertility/Conception/Family Planning [COMING SOON!]Vitamin InjectionsBloodwork/Lab Testing (Prenatal labs, Genetic testing, infertility work-up, Hormone levels, nutritional/vitamin deficiencies, Thyroid levels, Cholesterol, Pharmacogenomics, Cancer Screening, etc.)Gut Health/Microbiome/Immunity (COMING SOON!)Women's Health Services (Prenatal/postpartum care, Menopause/Perimenopause, Long-acting contraception -IUDs, Nexplanon, other birth control options, pap smear, etc) [COMING SOON!]IV Infusions (Migraine, Nausea/vomiting, Anemia, Immune Support [COMING SOON!]Weight Loss Support [COMING SOON!]Sexual Health (low libido, Incontinence, Sexually Transmitted Infections, Hypoactive Sexual Desire Disorder [COMING SOON!]Reason for Visit *Do you prefer In-person or telehealth visit? *In-PersonTelehealth/VirtualNo PreferenceCOMMENTS/OTHERIf no other comments, type N/AWhat best describes your financial situation? *I have insurance and I only want services my insurance will coverI don't have insurance and I want join the membership or pay-per-visit programI have insurance but I want instead join the membership or pay-per-visit programIf we are NOT in-network with your plan, are you still willing to pay the $125 Intake visit fee?Yes, I will pay the intake visit feeNo, I only want in-network provider/servicesDeposit Acknowledgment Statement:I understand that a non-refundable deposit is required to confirm my appointment: $50 (for established patients using insurance); $75 (for new patient with insurance); or $99 (self-pay patients)This will be applied to your visit. If we are not in-network, no additional charges will occur without your approval. A self-pay plan can be created, and you may submit a superbill to your insurance for reimbursement.InsuranceInsurance 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 Drag & Drop Files, Choose Files to Upload Upload Front and Back of Picture ID Card * Drag & Drop Files, Choose Files to Upload Insurance Guarantor? *SelfOtherGuarantor's Name *FirstLastGuarantor's Date of Birth *Guarantor's Address (If Different than patient)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/AotherCardiovascular *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/AOtherMusculoskeletal *Joint painMuscle painBack painSwelling in jointsLimited range of motionN/AOtherDermatological *RashesItchingDry or oily skinAcne or skin eruptionsMoles with changes in size, shape, or colorN/AOtherPsychiatric *DepressionAnxietyMood swingsHallucinations or delusionsSleep disturbancesSuicidal thoughtsHomicidal thoughtsSelf-Harm thoughtsN/AIrritabilityHyperactiveUnable to concentrateSubstance Use (Last 6-12 months) *Drink AlcoholUse tobacco/nicotine productsUse recreational/street drugsUse/Drink caffeine productsNoneOther of history, Genitourinary Other 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.TYPED NAME as ELECTRONIC SIGNATURE *Consultation FeeNew Patient Consultation Fee (Self-pay Patient)Consult Fee - $175.00Enter Discount code: VJM5RN4A Apply Discount code brings consult fee to $99Total$0.00DepositNon-refundable deposit will be applied to your appointment and/or any outstanding account fees. Deposit DateEst/Follow-up Security DepositPrice: $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. Which Pay Service do you prefer?PayPalSquareSquareCredit Card field is disabled, Square account connection is missing.Signature Consent *By typing or signing my name below, I acknowledge that the information provided is true and accurate and that the electronic signature has the same legal force and effect as a manual signature.Signature Clear Signature Confirm Your Deposit/Consultation Fee *By checking this box, I confirm that the applicable deposit/consult fee has been/will be paid. I understand that no further payment is required at this time. *After form and deposit/consult submission, you will receive the link to self-schedule your appointmentSubmitSave and Resume Later Heads up! Saving your progress now will store a copy of your entry on this server and the site owner may have access to it. For security reasons, sensitive information such as credit cards and mailing addresses, along with file uploads will have to be re-entered when you resume. Continue Go Back Your form entry has been saved and a unique link has been created which you can access to resume this form. Enter your email address to receive the link via email. Alternatively, you can copy and save the link below. Please note, this link should not be shared and will expire in 3 days, afterwards your form entry will be deleted. Copy Link Email * Send Link More Ways Phone (You can call but text is better):402-884-9059 Fax :833-875-0053 Email: info@j2wllc.org Address: 401 East Gold Coast Rd Suite #340, Papillion, NE 68046 Follow Me On Social Media
