Intake Forms

Welcome New Patients

At Fenske Holistic Healthcare, we appreciate the trust you have placed in us to work together with you to regain and maintain your health.  We pride ourselves in our commitment to our patients.  We look after each patient as we would the closest member of our family.

After calling our office to schedule your initial appointment, please complete the appropriate forms provided below.  Based on the initial appointment you scheduled you would select forms for either Chiropractic, Functional Medicine – COMPREHENSIVE, or Functional Medicine – WELLNESS.  Initial Functional Medicine appointments will require a Request for Medical Records form to be returned to our office so Dr Fenske can review your medical history before your appointment.  Once downloaded, all of these forms can be filled in electronically and emailed back to us (note that you will need to download them first to be able to save any date you enter).   Alternatively you may print and mail them – but please keep a copy before mailing.  The Patient Acceptance Form below gives detailed information on what Functional Medicine patients can expect leading up to, and during their initial office visits.

Chiropractic patients please bring the completed paperwork to your initial appointment.

Functional Medicine patients please send us your completed paperwork prior to your appointment  (email to Info@DrFenske.com, fax to 608.836.8863, mail or drop off at the address below).  Although completing the paperwork will take time, the more I know about you the better I will be able to assist you.

We look forward to a long and positive relationship with you.  Please consider us your family holistic healthcare office and do not hesitate to ask us how we can be of help in any and all circumstances regarding your health and the health of your family.

Dr. Nicole Fenske

 

A Note About Chemical Sensitivity

During your visit to our office please be aware that many of our patients are sensitive to the chemicals and/or other ingredients used in PERFUMES, HAIR SPRAYS, and other SCENTED BODY PRODUCTS.

Out of respect for these patients please restrict the use of these products when visiting our office. Thank you!

 

Intake forms for new Chiropractic patients

NOTE: Dr Fenske is NOT currently accepting new CHIROPRACTIC patients.

Chiropractic Intake Forms
Completed forms due at your initial appointment.

 

Intake forms for new Functional Medicine – Comprehensive patients

To-Do List (FM-Comprehensive)
Use this to help you prepare your intake forms.

Request for Medical Records (FM – Comprehensive)
So that we may request your past medical records from other providers with time for Dr Fenske to review them, please return this form within TWO DAYS of scheduling your initial appointment.

FM Comprehensive Intake Forms
Please return these pages within ONE WEEK of scheduling your initial appointment.

 

 

Intake forms for new Functional Medicine – Wellness patients

To-Do List (FM-Wellness)
Use this to help you prepare your intake forms.

Request for Medical Records (FM – Wellness)
So that we may request your past medical records from other providers with time for Dr Fenske to review them, please return this form within TWO DAYS of scheduling your initial appointment.

FM Wellness Intake Forms
Please return these pages within ONE WEEK of scheduling your initial appointment.

 

 

Intake forms for Health Coaching

Health Coaching Intake Form

If you are seeing our Health Coach, please bring both of these forms to your first appointment.

Health Coaching Informed Consent Form

 

Have questions about any of the forms?  Please call our office at (608) 836-8883

 Privacy Policy

Notice of Privacy Practices – click here to see how we protect your personal information.