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Patient Enrollment Form - Invigoration Telehealth Practices

Patient Enrollment

Invigoration Telehealth Practices - Complete your enrollment for virtual nursing consultations

I. Patient Information

II. Contact Details

III. Emergency Contact

IV. Referral Information

V. Health Information

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

VI. Wellness Goals

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

VII. Consent Acknowledgement

Privacy Notice: All information is securely transmitted to Invigoration Telehealth Practices and protected under HIPAA guidelines. Your data will only be used for providing nursing care services.

I provide the best online consultations as a registered nurse, offering professional, compassionate, and personalized care to support your health and well-being.

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