Medical Forms

HIPAA Form

Informed Consent to Treat (2 pages print in color)

Patient Confidential Form

Health History Form

Financial policy

Please bring any additional information to inform the doctor about Your situation.  

FAX the completed and signed form(s) to Dr. Christopher Jackson, Ph.D., D.O.M., at: 

FAX  727-521-8781  

or

E-mail and attach a scanned copy of the completed and signed form(s):

E-mail  apathtowellnessllc@Gmail.com