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 on Behalf of the Patient

Patient Representative

Relationship to Patient

Mother
Father
Guardian
Other

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)

Patient Chronic Dermatological

Inquiry Only - NOT Patient Care Related

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

Patient Name

First

Last

Patient Gender

Female
Male
Other

Patient Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State

Zip Code

What service(s) are you interested in?

Reason for Visit

Visit Preference?

In-Person
Telehealth/Virtual
No Preference

What days of the week and Time Frames work best?

COMMENTS/OTHER

What best describes the patient's financial situation?

Insurance

Insurance Name

Claim Address

Address Line 1

Address Line 2

City

State

Zip Code

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 3 files.

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 3 files.

Insurance Guarantor?

Guarantor's Name

First

Last

Guarantor's Date of Birth

Guarantor's Address (If Different than patient)

Address Line 1

Address Line 2

City

State

Zip Code

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

Substance Use (Last 6-12 months)

Other Symptoms/Conditions Not Listed

Consent and Acknowledgment (Patient Representative)

Consent to Proceed (Patient Representative)

I (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 (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 understand that submitting this information is voluntary. I understand that I can be charged the additional fees that my insurance does not cover. This consent is valid for 12 months from the date of submission or until I revoke it in writing.

Telehealth Consent (Patient Representative)

I (Patient Representative) 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.

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 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.