Patient Intake Form

Please note, our program is fully online (visits by phone currently) and is self pay and costs $75 per week. Your visits are not covered under insurance due to the time and effort Dr. Jandes dedicates to each patient at each visit. Your prescriptions and lab tests will most likely be covered under your insurance plan and we have low-cost options if you're uninsured. Our main clinic day is Tuesday, but we have options for Friday visits as well if that better suits your needs. You will have a visit with Dr. Jandes and our counselor weekly for the first 4-6 weeks and then your visits will be every 2 weeks thereafter. If you agree to all of the above please continue filling out this form and a staff member will text you within 24 hours of receipt to setup your first visit. Sometimes this can be scheduled the same day but if not, we make sure we get new patients seen within 24-48 hours. You can text us with any questions 24/7 at 606-618-0125. Thanks!

Email*

example@example.com

Today's Date

Date

Name*

First NameMiddle NameLast Name

First Name*

Middle Name

Last Name*

Preferred Name, if different than above

Birth Gender*

MaleFemale

Date of Birth*

Date

Phone number*

10-digit

Social Security Number*

Address*

Address 1

Address 2

CityState

Zip Code

Genetic Background*

Weight*

pounds

Height*

feet and inches

How did you hear about our practice?*

Patient Name (We have a referral bonus program)

First NameLast Name

Doctor name

First NameLast Name

Do you have insurance?*

YesNo

Who is your insurance carrier?*

Do you have Medicaid?*

YesNo

What is your Medicaid ID Number?

Medicaid ID #

Do you have Medicare?*

YesNo

What is your Medicare ID Number?

Medicaid ID #

What is your Preferred Pharmacy?*

Current occupation?*

We need picture of your face for our medical records. Please choose an option*

I have a picture I would like to uploadI would like to take a picture now with my device

Please upload a picture of your face

Browse Files

Upload picture from file

Take a picture

Are you active-duty, reservist, veteran, or retiree of the US Military.

YesNo

Please take a picture of your military ID card to receive our military discount.

Patient Intake Form

Substance Use History

Allergies

Lifestyle Review

Lifestyle Review

Lifestyle review

Lifestyle Review

Lifestyle Review

Women's History

Medications / Supplements

Health Goal