Scheduling Intake Form (New and Return Patients)

Your Name

First

Last

Your Phone Number

Your Email

Email

Confirm Email

Check This Box If You Are Completing This Form on Behalf of the Patient

Patient Representative

What is Your Relationship to the Patient?

Has the patient agreed to be contacted by Journey2Wellness/Restore Optimization Clinic?

Yes
No
Unsure

How did you hear about us?

Is this request for 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)

Inquiry Only - NOT Patient Care Related

Send question(s) to email: info@j2wllc.org

Patient Name

First

Last

Preferred Name (Optional)

First

Last

Sex Assigned at Birth

Female
Male

(Required for insurance verification and certain medical services)

Gender Identity (Optional)

Patient Date of Birth

Upload Front and Back of Picture ID Card

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera You can upload up to 6 files.

Patient Photo ID

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

How can we help you/patient?

Reason for Requesting a Visit

What service(s) would you like to learn more about??

Visit Preference?

In-Person
Telehealth/Virtual
No Preference

What Day(s) of the Week and Time Frame(s) work best?

COMMENTS/OTHER

What best describes the patient's financial situation?

Primary Health Insurance

Primary Insurance Name

Insurance Company's Claim Address

Address Line 1

Address Line 2

City

State

Zip Code

Primary Insurance Holder's Employer

Member ID#/Group ID#

Upload Front and Back of Insurance Card

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera You can upload up to 7 files.

Primary Insurance Subscriber/Policy Holder/Guarantor?

Primary Subscriber/Policy Holder/Guarantor's Name

First

Last

Primary Subscriber/Policy Holder/Guarantor's Date of Birth

Primary Subscriber/Policy Holder/Guarantor's Address (If Different than patient)

Address Line 1

Address Line 2

City

State

Zip Code

Primary Subscriber/Policy Holder/Guarantor's Email

Email

Confirm Email

Primary Subscriber/Policy Holder/Guarantor's Phone #

Do You Have a Secondary Insurance?

Yes
No

Secondary Health Insurance

Secondary Insurance Subscriber/Policy Holder/Guarantor?

Secondary Insurance Name

Secondary Member ID#/Group ID#

Secondary Insurance Holder's Employer

Secondary Insurance Company's Claim Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Upload Front and Back of Insurance Card

Drag & Drop Files, Choose Files to Upload, or Capture With Your Camera You can upload up to 7 files.

Secondary Subscriber/Policy Holder/Guarantor's Name

First

Last

Secondary Subscriber/Policy Holder/Guarantor's Date of Birth

Secondary Subscriber/Policy Holder/Guarantor's Address (If Different than patient)

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Subscriber/Policy Holder/Guarantor's Email

Email

Confirm Email

Secondary Subscriber/Policy Holder/Guarantor's Phone #

Past Medical History (PMH)

Chronic Illnesses

Surgeries

Allergies

Current Meds and supplements

Established Patient Past Medical History

Any changes since your last visit?

New surgeries/procedures, injuries/illnesses, family history, medication, etc?

Type: N/A or None if no changes

Review of Systems (ROS)

Patients are often asked to check any symptoms they currently have or have had in the last 6-12 months.

Respiratory

Cardiovascular

Neurological

Gastrointestinal

Endocrine

Genitourinary

Musculoskeletal

Dermatological

Psychiatric

Insurance? (If Subscriber/Policy

Substance Use (Last 6-12 months)

Other Symptoms/Conditions Not Listed

Consent and Acknowledgment (Patient Representative)

Consent to Proceed (Patient Representative)

I, on behalf of the patient (Patient Representative), affirm that I am the legal guardian, healthcare proxy, or authorized representative for the patient listed above and have the authority to act on their behalf.

Privacy Statement (Patient Representative)

I, on behalf of the patient (Patient Representative), hereby authorize Journey2Wellness/Restore Optimization Clinic representatives to receive, use, and disclose the personal demographic and medical information provided in this form for the purposes of evaluating for care, scheduling, or initiating services. I, on behalf of the patient (Patient Representative), understand that submitting this information is voluntary. I, on behalf of the patient (Patient Representative), understand that the patient can be charged the additional fees that insurance does not cover. This consent is valid for 12 months from the date of submission or until patient/patient representative revokes it in writing.

Telehealth Consent (Patient Representative)

I, on behalf of the patient (Patient Representative), understand that all laws that protect patient privacy regarding medical history or information also apply to telehealth practices. While Journey2Wellness/ Restore Optimization Clinic representatives take measures to protect online information, and acknowledge that internet communications are not entirely secure. I, on behalf of the patient (Patient Representative), understand that patient consent can be withdrawn at any time, and that this will not affect any future treatment procedures. I, on behalf of the patient (Patient Representative), authorize health care professionals to use telehealth for treatment and diagnosis.

Consent and Acknowledgment

Consent to Proceed

I hereby give consent to undergo the health services as requested above. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance.

Privacy Statement

I confirm that I am voluntarily providing my personal demographics and medical information. I authorize Journey2Wellness/Restore Optimization Clinic and its representatives to use this information to contact me, initiate services, schedule appointments, or process consultation requests. I understand that this information is transmitted securely and handled in accordance with the HIPAA Privacy Rule and your Privacy Policy. I acknowledge that while measures are taken to protect online data, internet communications are not entirely secure. This consent remains valid for 12 months from the date of this submission or until revoked in writing.

Telehealth Consent

I understand that all laws that protect my privacy regarding medical history or information also apply to telehealth practices. While Journey2Wellness/ Restore Optimization Clinic representatives take measures to protect online information, I acknowledge that internet communications are not entirely secure. I understand that I can withdraw my consent at any time, and that this will not affect any future treatment procedures. I authorize health care professionals to use telehealth for treatment and diagnosis.

TYPED NAME as ELECTRONIC SIGNATURE

Signature Consent

I, as the patient or Patient Representative, acknowledge that I am not submitting this form as a vendor, solicitor, or telemarketer; that my electronic signature has the same legal force and effect as a handwritten signature; and that the information provided is true and accurate.