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Patient Enrollment Form

I. Patient Information

Full Name Date of Birth Gender Identity

Female Male Non-binary Other

Preferred Pronouns Marital Status Occupation Employer

II. Contact Details

Primary Phone Number Email Address Mailing Address City State Zip Code Preferred Contact Method

Phone Text Email

III. Emergency Contact

Full Name Relationship Phone Number

IV. Referral Information

How did you hear about us?

Website Social Media Friend/Family Practitioner Event Other

V. Health Information

Currently under physician or mental health care?

Yes No

If yes, please explain Taking any medications or supplements?

Yes No

If yes, please list Recent surgeries, diagnoses, or major health concerns?

Yes No

If yes, please describe Currently pregnant?

Yes No N/A

History of (check all that apply):

Chronic Pain Anxiety Depression High Blood Pressure PTSD Autoimmune Disorder Cancer Diabetes

Other

VI. Wellness Goals & Intentions

What brings you in today? Primary goals for our sessions (check all):

Stress Relief Emotional Healing Pain Management Spiritual Connection Chakra Balancing Energy Clearing Chronic Dis-Ease Management Autoimmune Dis-Ease Relief Other

VII. Consent & Acknowledgement

I acknowledge that the services provided are not a substitute for medical care and do not diagnose, treat, or cure disease. I understand that I should consult with my healthcare provider for any medical concerns.
I give permission to be contacted for appointment reminders, wellness updates, or follow-ups.

Signature Date

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“I provide professional and compassionate online consultation as a registered nurse to support your health and wellbeing.”

(863) 605-8509
info@kencare.telehealhpractices.com

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