Jennings Health | Family Application

Jennings Health | Family Application

Thank you for your interest in Jennings Health. We are a small, dedicated whole-family practice providing integrative, preventive, and personalized care for parents and children together. Applications must include both adults and children, and priority is given to larger family units with three or more applicants. Please complete the application for your entire family.
Where did you hear about us?
Were you referred by a current Jennings Health family or by a practitioner?
Name of referring patient/family or practitioner

First NameLast Name
Your Family Information

Jennings Health is designed to care for families together. Please list all members of your household who intend to join Jennings Health, including adults, children, and any expected babies (with due date). Please note that Jennings Health is a whole-family practice, and partial family applications are rarely accepted.
Primary Contact

First NameLast Name
Phone Number
Mobile phone number required. All communication is via text message.Format: (000) 000-0000.
E-mail
Are you currently expecting a baby?
Please list all members of your household who intend to join Jennings Health, including adults, children, and any expected babies (with due date).
Is there anyone in your immediate family who is not included on this application?
If Yes, please tell us who is not included and why:
Knowing which family members are applying helps us understand how your family plans to use the practice and whether you are seeking care for your entire family or only select family members.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Engagement and Commitment
Do Mom and Dad live together in the same household and share a unified, proactive approach to health, including a focus on prevention and thoughtful use of medications?
Health Philosophy
Describe your family’s core health values. How does Jennings Health's perspective align with your family’s approach to health?
We are looking for families who share our commitment to prevention, personal responsibility, informed decision-making, holistic health, and the Make America Healthy Again mindset.
What has been missing from your family's healthcare experience that you hope to find at Jennings Health?
Tell us about your experiences with healthcare so far and what you're hoping will be different moving forward.
What motivates you to pursue a more preventive and holistic approach to healthcare?
Help us understand the experiences, values, or goals that have influenced your family's approach to health and healthcare.
What are some examples of ways your family prioritizes health in everyday life?
Examples may include organic or locally sourced foods, reducing exposures from pesticides and plastics, outdoor play, movement, sleep, homeschooling, faith, or other lifestyle choices that support your family's health. We are interested in understanding how prevention shows up in your family's everyday life.
We recognize that every family approaches treatment decisions differently. Help us understand how your family thinks about medications and when you feel they are most appropriate.
Examples are helpful. Tell us how your family typically approaches treatment decisions and what factors influence when medications are or are not considered.
Vaccination Preferences

Understanding your vaccination approach helps us ensure our care is a good fit for your family.
Jennings Health supports families in making informed choices about vaccines. For your child(ren), which of the following best describes your current plan?

Other
Additional Information
Why is now the right time for your family to apply to Jennings Health? We'd like to understand what prompted you to begin looking for a new healthcare relationship at this point in time.
Examples may include a new baby, a move, changes in your healthcare needs, evolving health goals, or a transition from another healthcare practice. If you have been asked to leave a practice, dismissed from a practice, or chose to leave because of differences in healthcare philosophy or vaccine policies, please share those details.
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 due to Jennings Health's small patient panel size and the high cost of vaccines, Jennings Health does not stock or administer vaccines.
I acknowledge that Jennings Health is an out-of-network provider for all insurance carriers and does not accept insurance for payment. Jennings Health will not communicate with your insurance carrier.
I acknowledge that PAYMENT for each visit or service at Jennings Health is due at the time of BOOKING. Accepted payment methods include credit, debit, & HSA/FSA.
I understand that Jennings Health communicates by TEXT MESSAGE and agree to add 571-506-7265 to my contacts to avoid missing important updates about my application, acceptance, and scheduling.
Thank you for your interest in Jennings Health!

Please note that submitting an application does not automatically place your family on a waitlist. Each application is carefully reviewed, and acceptance or a specific timeline for review cannot be guaranteed.

Families are considered on a rolling basis as space becomes available. Additional consideration is given to factors such as family size, anticipated newborns, application timing, and overall alignment with our whole-family, integrative care model.

If your family is selected, we will contact you by text message to discuss next steps.

We appreciate your patience as we thoughtfully and intentionally grow our panel of families.
Should be Empty:

Jennings Health | Family Application

Your Family Information

Engagement and Commitment

Health Philosophy

Vaccination Preferences

Additional Information

Acknowledgements