General Intake & Consent Form

General Intake & Consent Form

Please complete this form to provide your medical history, review clinic policies, and give informed consent for evaluation and treatment at Optimize by JaeNix.
Patient Identification

Please provide your personal information.
Full Legal Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
TXCOCTIAWAFLVAVT
Emergency Contact Name & Phone (optional)
Medical History (General)

Please complete to the best of your knowledge.
Current Medications, Hormones, Peptides, or Supplements
Allergies (medications, latex, lidocaine, etc.)*
Diabetes / insulin resistanceThyroid disorderPCOSHigh blood pressureHigh cholesterolHeart diseaseStroke or blood clotsCancer (current or past)Autoimmune diseaseLiver diseaseKidney diseaseAnxiety / depression / ADHDNone of the above
Past surgeries or hospitalizations
Height
Weight
Service Interests

Please check all services you are interested in discussing today.
Medical weight loss / metabolic therapyHormone optimization (BHRT / TRT)Peptide therapySexual healthHair restorationAesthetics (Neurotoxins, Dermal Fillers, Biostimulators, PRP/PRF)IV therapy / injection servicesLongevity, performance, or energy optimizationOther
Other services you may be interested in in the future (optional)
Primary goals or concerns you’d like addressed*
Government ID Verification

A valid government-issued photo ID may be required for certain services. Upload of photo ID (front and back) may be required prior to prescribing testosterone.
Upload a photo of your government-issued ID (front and back)

Cancelof
Telehealth Consent & Location Verification

Some services may be provided via telehealth using secure, HIPAA-compliant platforms. Please review and consent if appropriate.
I consent to telehealth servicesI do not consent
General Treatment Consent

Please review the treatment consent. All treatments require medical evaluation and approval. Results are not guaranteed and all treatments carry potential risks, benefits, and alternatives.
I consent to evaluation and treatmentI do not consent
Financial Policies & Payment Authorization

A valid payment method must be kept on file. A $100 non-refundable booking deposit may be required to secure your appointment and will be applied toward your visit.
Cancellation & No-Show Policy

Cancellations must be made at least 24 hours in advance. Late cancellations and no-shows may result in forfeiture of deposit and additional fees.
Patient Attestation & Signature

Please certify that the information provided is accurate and complete. Your signature is required.
Patient Name (typed)*
Signature*
Date*

MonthDayYear
Date
Should be Empty:

General Intake & Consent Form

Patient Identification

Medical History (General)

Service Interests

Government ID Verification

Telehealth Consent & Location Verification

General Treatment Consent

Financial Policies & Payment Authorization

Cancellation & No-Show Policy

Patient Attestation & Signature