New Patient Intake | Lavena Health

Step 1 of 5

Welcome to Lavena Health

Not sure which program is right for you? Complete this general intake and our physician will personally review your health profile and recommend the best plan.

Personal Details

First Name *

Last Name *

Date of Birth *

Biological Sex *

State *

Email *

Phone *

Street Address *

City *

ZIP Code *

Height

Weight (lbs)

BMI (auto)

How did you hear about us?

If referred by someone, please share their name (optional)

Step 5 of 5

Consent & Signature

Please read and sign. Your electronic signature is legally binding under Florida Statute §668.50.

Patient Consent for Evaluation

Purpose of This Intake

This general intake form is for the purpose of establishing a patient-provider relationship with Lavena Health and requesting a physician evaluation. No specific treatment or prescription is authorized by submitting this form. Your physician will review your intake, contact you to discuss your goals and health history, and recommend an appropriate treatment plan.

Telehealth Consent

I consent to receive healthcare services via telehealth, which may include video, audio, or secure messaging. I understand that telehealth has limitations and that my provider may recommend an in-person visit if clinically appropriate. I confirm I am physically located in Florida at the time of this consultation request.

Direct-Pay & Privacy

I understand that Lavena Health is a direct-pay, cash-pay clinic. No insurance is billed. My protected health information will be handled in accordance with HIPAA. I certify that all information in this intake is truthful and complete.

Identity Verification

Why we ask: Florida law and federal telehealth regulations require that prescribing physicians verify patient identity before issuing prescriptions. Your attestation below satisfies this requirement for your initial intake. A government-issued photo ID may be requested at or before your first consultation.

I attest that I am the person named in this intake form and that all personal information provided (name, date of birth, address) is accurate and truthful.

I understand that a valid government-issued photo ID (driver's license, passport, or state ID) may be requested before my prescription is issued, and I agree to provide one upon request.

I confirm that I am a resident of the state selected in this form and am physically located within that state at the time of this consultation request.

Date of Birth (re-enter to confirm identity)

Acknowledgments & Signature

I consent to telehealth evaluation and understand its limitations.

I acknowledge Lavena Health's HIPAA privacy practices and direct-pay model.

I confirm I am 18 or older, am the patient named in this form, and voluntarily consent to a physician evaluation through Lavena Health. All information provided is truthful.

Full Legal Name *

Or type your full legal name as your electronic signature

Today's Date *

Electronic Signature Notice: By typing your name and submitting, you provide a legally binding electronic signature under Florida Statute §668.50 and the federal E-SIGN Act.

ID Verification — Optional but recommended

Upload a photo of your government-issued ID to verify your identity. This helps your physician review your file faster.

📷 Tap to photograph ID or upload a file JPEG, PNG or PDF · Max 6MB · Encrypted & HIPAA secure

Welcome to Lavena Health

Your Health Goals

Medical History

Medications & Lifestyle

Consent & Signature

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