JFAO Healthcare | SimplePractice

Who would be receiving care?

Someone else

Your info

First name

Last name

Phone

Name you go by

Date of birth

Gender

Sex at birth

For insurance verification

Reason for care

Reason for appointment

Tell us the reasons you are requesting an appointment. example: primary care, not feeling well, need a physical etc.

Administrative

Inquiry reason

Referral source

Enter how you were referred to our services

Billing & Payment

Payment method

How do you plan to pay?

Client Preferences

Preferred appointment times

Morning Afternoon Evening Weekend

Is there anything that the practitioner needs to know?

For example: what you'd like to focus on, insurance or payment questions, etc.

Limited to 600 characters

For medical emergencies, contact your healthcare provider or call 911. For mental health crises, call or text 988.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice. You also agree not to submit any payment information, including credit or debit card details, through this form.