Free Consultation

To schedule a free consultation, or if you have been instructed to by the Doctor, please fill out this form. The doctor will contact you shortly.

Section Three: Your Medical History
List any Major Illnesses (with approx. dates)
List any surgeries or operations (with approx. dates)
List past or current accidents or injuries (with approx. dates)
Marital Status*
- Single
- Married
- Divorced
- Widowed
Name of Spouse
First Last
Please describe your spouse's health:
Please list the names, age & sex of your children and any physical conditions or concerns they may have
Any family history of serious illnesses? (Check all that apply)
- Cancer
- Diabetes
- Heart
- Other
You Selected "Other" above. Please describe*
Please list any household pets or other animals you or your family members are in close contact with:

Section Four: Disclaimers and Consent

Privacy/Digital Record Disclaimer
Disclaimer Text Disclaimer Text Disclaimer Text Disclaimer Text Disclaimer Text Disclaimer Text Disclaimer Text Disclaimer Text Disclaimer Text Disclaimer Text
Fees
All fees incurred are my sole responsibility and Fees are due at the time of service.

If you have questions about Fees please speak up, the Doctor will be more than happy to explain our fees.
Is the patient a minor?*
I accept the terms and conditions above.
Patient's Signature*
I accept the terms and conditions above and I authorize Dr. Jenison to treat the minor entered on this form.
Parent/Guardian's Signature*

Section One: Personal Information