Jennings Health | Family Application

Jennings Health | Family Application

Thank you for your interest in Jennings Health. We take pride in building a small, dedicated panel of families who are deeply committed to integrative, preventive, and family-centered care. To ensure that your family’s values align with our practice philosophy, please complete the following application. If your family is selected, we’ll reach out to discuss next steps. Due to high demand, there may be a wait before we can welcome you to Jennings Health. This thoughtful process ensures that each family receives the high-quality, personalized care they deserve.
Where did you hear about us?*

Database: Dr. Green Mom Medical Freedom Healthcare Providers DatabseDatabase: The Institute for Functional MedicineFamily member or friend (please list who we can thank below!)Referral from another practitionerSearch engineSocial mediaTransfer: our family was under Stef's care at Sterling Family Practice
Referred by (family, friend, practitioner)

First NameLast Name
Family Information

At Jennings Health, we want to care for your whole family. That’s why every child needs to be registered with an adult—and every adult with a child.
Please list all family members you are seeking care for (including expected babies)*
Primary Contact*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Health Philosophy
Describe your family’s core health values. How does Jennings Health's perspective align with your family’s approach to health?*
We most enjoy partnering with families who align with and embrace the "Make America Healthy Again" mindset. We’re looking for families who share our deep commitment to holistic, integrative, and preventive healthcare.
What motivates you to pursue a more natural, preventive approach?*
Are you comfortable adopting new habits that may require commitment, patience, and lifestyle changes? Are you looking for a provider to partner with you in health education and wellness exploration?
How does your family approach daily lifestyle choices related to health?*
Do you prioritize organic or locally-sourced foods? How important is it to reduce environmental exposures, such as from pesticides or plastics? Would you say your family aims for prevention first rather than “quick fixes”?(Examples are helpful!)
Are there any specific health challenges or goals that bring you to Jennings Health?*
This will help us understand your family’s health journey and goals within a holistic framework.
In your family’s experience, what role should medications play in healthcare?*
Describe any alternative methods or lifestyle adjustments you prefer before considering medications. Are you open to exploring natural remedies and lifestyle-based therapies as first steps?
Engagement and Commitment
Do all of your immediate family members support this approach to health?*

YesNo
Vaccination Preferences
Jennings Health supports your family's medical autonomy. What are your expectations regarding vaccination guidance and your family’s health?*
Jennings Health does not stock or administer vaccines. We do not require adherence to a specific vaccine schedule.
Additional Information
Is there anything else you would like us to know?
We value transparency and want to ensure we can provide the best possible support aligned with our practice philosophy.
Acknowledgements
I acknowledge that Jennings Health is an out-of-network provider for all insurance carriers and does not accept insurance for payment. Payment for each visit is due at the time of booking. Accepted payment methods include credit, debit, HSA, or FSA debit card.*

Yes, I acknowledge that Jennings Health does not accept insurance, and that payment is due at the time of booking.
Thank you for your interest in Jennings Health!

If your family is selected, we’ll reach out to discuss next steps.
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Jennings Health | Family Application

Family Information

Health Philosophy

Engagement and Commitment

Vaccination Preferences

Additional Information

Acknowledgements