General Intake & Consent Form

General Intake & Consent Form | Optimize by JaeNix

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
State you will be physically located in at the time of your visit (required for telehealth)
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.)
Medical Conditions (check all that apply)
Past surgeries or hospitalizations
Height
Weight
Service Interests

Please check all services you are interested in discussing today.
Please check all services you are interested in discussing today

Other
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 services from Optimize by JaeNix when medically appropriate.
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 understand and consent to evaluation and treatment under the clinic's policies and procedures.
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 | Optimize by JaeNix

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