Contact & Communication Consent Form

Please correct the errors described below.


1. What's your appointment preference?

Date of Birth

We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail. Please call or email if you have questions now - or prefer a non-digital intake process.

Next Step? Complete the INTAKE FORM for your provider. Please select a numerical code and use the code to complete the intake form. All forms are HIPAA-compliant and encrypted.

My Personal Number:

Your message will be encrypted and can only be read by Kama Jensen.