Form – Informed Consent

By signing this form, I the undersigned patient, acknowledge that I am choosing to work with Dr. Jennifer L. Sims DC, licensed Chiropractic Physician.

Dr. Jennifer L. Sims is not a primary care physician. Blue Sky Health and Wellness encourages you to have a primary care physician. Dr. Sims specializes in working with pediatrics and women’s health from an alternative, holistic perspective. Her services do not take the place of your primary care physician.

Please complete the information below to acknowledge.

I, hereby acknowledge that I have read and understand the policies of Blue Sky Health and Wellness.
Please provide Name of Physician, Office Email, Office Street Address and Office Phone # here.
PLEASE SIGN HERE FOR YOUR E-SIGNATURE.
PLEASE SIGN HERE FOR YOUR E-SIGNATURE.
PLEASE SIGN HERE FOR YOUR E-SIGNATURE.
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Please do not submit any Protected Health Information (PHI).

This field is for validation purposes and should be left unchanged.

Please do not submit any Protected Health Information (PHI).