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Secure Patient Intake

Your information is securely managed and directly integrated into Jane Software, ensuring a seamless and private experience for your virtual care.

Patient Intake Form

Please complete this form to help us provide you with the best possible care.


Please fill out the form carefully. All data is processed through Jane Software for secure, clinical-grade medical record management and virtual care coordination.

Date of Birth
Year
Month
Day
Gender
Female
Male
Non-binary
Prefer not to say
Other

Please provide your full mailing address for our records.

Home Address

What Happens Next

STEP 01
Secure Transmission

Your information is immediately encrypted and synced with Jane Software to ensure the highest level of privacy.

STEP 02
Clinical Assessment

Jane Rolfe NP will personally review your intake form to prepare for your specific healthcare needs and symptoms.

STEP 03
Consultation Portal

Check your email for a secure link to access the patient portal and select a time that fits your schedule.

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