Scheduling Intake Form (New and Return Patients)

Consent Insurance If

Name

First

Last

Phone Number

Email

Are 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)

Inquiry Only - NOT Patient Care Related

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

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

Patient Representative

Gender

Female
Male
Other

Date of Birth

Address

Address Line 1

Address Line 2

City

State

Zip Code

What service(s) are you interested in?

Reason for Visit

Do you prefer In-person or telehealth visit?

In-Person
Telehealth/Virtual
No Preference

What days of the week and Time Frames work best?

COMMENTS/OTHER

If no other comments, type N/A

What best describes your 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?

Self
Other

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.
I 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. While Journey2Wellness/Restore Optimization Clinic representatives take measures to protect online information, I acknowledge that internet communications are not entirely secure. This consent is valid for 12 months from the date of submission or until I revoke it in writing.

Telehealth Consent (Patient Representative)

I understand that all laws that protect my privacy regarding medical history or information also apply to telehealth practices. I understand that I can withdraw my consent at any time, and that this 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.

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.
I confirm that I am voluntarily providing my personal demographics and medical information. I authorize Journey2Wellness/Restore Optimization Clinic representatives to use this information to contact me, schedule an appointment, or process a consultation request. I understand that, this information is transmitted securely and handled in accordance with the HIPAA Privacy Rule and our Privacy Policy. While Journey2Wellness/Restore Optimization Clinic representatives take measures to protect online information, I acknowledge that internet communications are not entirely secure. I may revoke this authorization in writing at any time. The information provided will be used solely to initiate care.

Telehealth Consent

I understand that all laws that protect my privacy regarding medical history or information also apply to telehealth practices. I understand that I can withdraw my consent at any time, and that this 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

Signature Consent

By typing or signing my name, I acknowledge that the information provided is true and accurate and that the electronic signature has the same legal force and effect as a handwritten signature.