Optimize by JaeNix – DISCOVERY INTAKE FORM

Optimize by JaeNix – DISCOVERY INTAKE FORM
Thank you for booking your consultation!

Please complete the following form so we can be fully prepared for your visit. This will help us provide the best care and keep your information up to date in our system.
Name

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Date of Birth

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Address

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Medical Information
Current Medications/Supplements (please list):
Allergies (medication, latex, etc.):
Any major medical diagnoses (ex: diabetes, thyroid issues, hormone conditions, surgeries, etc.):
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Upload Valid Photo ID (REQUIRED FOR TESTOSTERONE THERAPY PATIENTS) We are legally required to verify your identity before prescribing testosterone, as it is a schedule III controlled substance. Please upload a clear photo of your government-issued ID (front & back).

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Card on File & Payment Policy Acknowledgment

All clients are required to keep a card on file to reserve appointments and process charges related to services.

I understand and agree that a valid credit/debit card must be kept on file for any services rendered. I authorize Optimize by JaeNix to charge my card on file for any services, late cancellations, or no-show fees in accordance with the policies outlined below.
Payment & Cancellation Policies

Please read and acknowledge our policies below:

Payment is due at the time of service.

For memberships or recurring treatments, automatic billing will occur monthly using the card on file.

Cancellations must be made at least 24 hours in advance to avoid a cancellation fee.

Late cancellations and no-shows will incur a $50 fee.
Consultation Goals – What Would You Like to Discuss? Please check all topics you’d like to discuss during your consultation:

Weight Loss / Metabolic HealthHormone Optimization / Testosterone TherapySexual Wellness / Erectile Function SupportPRF / EZ Gel / Regenerative AestheticsPeptide TherapyNAD+ TherapyFunctional Medicine / Lab TestingSkin Health / Aesthetic ConcernsVitamin Injections / IV TherapyGeneral Health & Longevity
Specific Questions or Concerns You’d Like Addressed:
Signature & Consent

Telehealth Acknowledgment & Consent (Required by Texas Law)

This consultation will be conducted via telehealth, using secure, HIPAA-compliant platforms. Please review and acknowledge the following:

I understand that this consultation is being provided through telemedicine and that medical services will be provided remotely.

I understand that telehealth services are provided by a licensed medical provider authorized to practice in the state of Texas.

I acknowledge that telehealth has limitations compared to in-person care, including possible delays due to technology, and I accept those limitations.

I understand that I may stop the telehealth session at any time and request an in-person consultation, if appropriate and available.

I consent to receive telehealth services from Optimize by JaeNix and their licensed providers.

By signing below, I acknowledge that I have provided accurate information to the best of my knowledge and that I consent to the policies described above.
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Optimize by JaeNix – DISCOVERY INTAKE FORM

Medical Information