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Patient Enrollment Form

Please complete all sections accurately. Your information is kept confidential and used only for your care.

I. Patient Information

Full Name

Date of Birth (MM/DD/YYYY)

Gender Identity

Preferred Pronouns

Marital Status

Occupation

Employer

II. Contact Details

Primary Phone Number

Email Address

Mailing Address

City

State

Zip Code

Preferred Contact Method

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

Are you currently under the care of a physician or mental health professional?

Are you taking any medications or supplements?

Have you had any recent surgeries, diagnoses, or major health concerns?

Are you currently pregnant?

Do you have 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?

What are your primary goals for our sessions?

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

Spring Telehealth

Manjuka Wijewardena provides the best online consultations as a Nurse Practitioner through Spring Telehealth, delivering personalized virtual care with proven excellence serving over 400 recovered patients.

Opening Hours

Mon - Fri 9AM - 8PM
Sat - Sun 10AM - 5PM

Social Media

"Have a heart that never hardens, a temper that never tires."

— Benjamin Franklin

Terms & Conditions

Refund Policy

Contact Info

(361) 232-8833
info@spring.telehealthpractices.com
United States