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 download and complete the appropriate form packet below (based on the initial appointment you scheduled and your age you would need one of  three form packets: Chiropractic, Functional Medicine – Comprehensive, or Functional Medicine – Wellness, plus a Request for Medical Records form for Functional Medicine patients).  Let us know if you prefer that we email or mail the forms to you.  The Patient Acceptance Form included in both Function Medicine packets 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  (fax to 608.836.8863 or email, 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 initial forms packet
Completed forms due at your initial appointment

(Children under 10) CHIROPRACTIC initial forms packet
Completed forms due at your initial appointment

Intake forms for new Functional Medicine – Comprehensive patients

Request for Medical Records
We need this form returned within TWO DAYS of scheduling your initial appointment so we can request your records from other providers you have seen, and receive them before your appointment.

FM-Comprehensive initial forms packet
Please return these forms within ONE WEEK of scheduling your initial appointment.

(Children under 10) Request for Medical Records
We need this form returned within TWO DAYS of scheduling your initial appointment so we can request your records from other providers you have seen, and receive them before your appointment.

(Children under 10) FM-Comprehensive initial forms packet
Please return these forms within ONE WEEK of scheduling your initial appointment.  For infants fill out all that applies.

Intake forms for new Functional Medicine – Wellness patients

Request for Medical Records
We need this form returned within TWO DAYS of scheduling your initial appointment so we can request your records from other providers you have seen, and receive them before your appointment.

FM-Wellness initial forms packet
Please return these forms within ONE WEEK of scheduling your initial appointment.

(Children under 10) Request for Medical Records
We need this form returned within TWO DAYS of scheduling your initial appointment so we can request your records from other providers you have seen, and receive them before your appointment.

(Children under 10) FM-Wellness initial forms packet
Please return these forms within ONE WEEK of scheduling your initial appointment.  For infants fill out all that applies.

 

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.