GI Janel Anywere New Client Information

This form collects and stores Personal Health Information. All information is sent and stored in encrypted format. Our technology vendor has signed a HIPPA Business Associate contract to ensure they comply with all HIPPA rules to protect your health information.

GI Janel Anywhere requires all new clients provide new client information via this online form. If you do not wish to use this form, please contact us immediately to cancel your new client appointment.
Do you consent to have your information securely transmitted and stored with GI Janel Anywere, Specialty Natural Medicine and our HIPPA compliant technology vendors?*

Yes, I consent to having GI Janel Anywere, Specialty Natural Medicine and it's HIPAA compliant vendors securely transmitting and storing my personal health information.
Do you understand that your consultation with Dr Kathleen Janel does not establish a Doctor/Patient relationship and that you should maintain a relationship with your local Doctor for medical needs, including labs and prescriptions?*

Yes, I understand that my consultation with Dr Kathleen Janel does not establish a Doctor/Patient relationship.

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Client Demographics